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Interest Survey for Personalized Library

Thank you for your interest in our Free Personalized Library Program! Please fill out this form to help us create a library tailored to your child’s needs and interests. Before you fill out the form, please read through the eligibility requirements, and sign to acknowledge that you do meet the requirements, and that you agree to the terms. Please initial each requirement and sign/date at the bottom.

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Eligibity Requirements

Financial need: The primary requirement for eligibility is having a financial need. This means the guardian has a strong desire to provide an age appropriate home library for the child but finds the cost to be a significant financial burden. Documentation will not be required.

Commitment to Use: The guardian should commit to utilizing the books provided by reading to or with the child(ren) regularly, fostering a love for reading and learning.  

Follow-up participation: Agreeing to participate in follow up surveys or feedback sessions to help the program assess the impact and effectiveness of the home library initiative 

Photo Release Consent: Applicants must consent to a photo release.  This means agreeing that a photo of a child with their new home library can be used for the program’s social media and promotional purposes.  This consent will be part of the application form and will require a signature from the guardian. 

Application form: Completion of an application form detailing: 

  • The guardian’s contact information.
  • Number and ages of children in the household 
  • A brief description of why the home library would be beneficial

Question 2 of 25

Did you meet and consent of the stipulated eligibility requirements?

A

Yes

B

No

Guardian information

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Question 4 of 25

Name

Question 5 of 25

Address

Question 6 of 25

Phone number

Question 7 of 25

Email Address

Question 8 of 25

Primary language spoken in the home

Child information

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Question 10 of 25

Name

Question 11 of 25

Age

Question 12 of 25

Grade

Question 13 of 25

Reading level

Question 14 of 25

Reading Habits and Preferences:

 

How often does your child read or get read to at home?

 

A

Daily

B

Several times a week

C

Once a week

D

Rarely

E

Never

Question 15 of 25

Reading Preferences: 

 

What type of books does your child enjoy?

 

(Select all that apply)
A

Picture books

B

Chapter books

C

Young adult novels

D

Graphic novels/comics

E

Non-fiction

F

Poetry

G

Others (please specify on the next space)

Question 16 of 25

If you answer, G. OTHERS on the last question, please write your child's reading preference.
If you didn't answer, G. OTHERS, type N/A. 

Question 17 of 25

Favorite Book Titles or Series: 

 

List any favorite book titles or series your child enjoys

 

 

 

Question 18 of 25

Topics of interest: 

What topics is your child interested in?

(Select all that apply)
A

Space

B

Dinosaurs

C

Animals

D

Superheroes

E

Trains

F

Princesses

G

Fairy tales

H

Pixar

I

Dragons

J

Science

K

Cooking

L

Drawing

M

Unicorns

N

Cars

O

Others (please specify on the next space)

Question 19 of 25

If you answer, O. OTHERS on the last question, please write your child's topic of interest
If you didn't answer, G. OTHERS, type N/A. 

Question 20 of 25

List any specific movies/TV shows or characters your child is interested in

 

Question 21 of 25

Does your child have any specific reading challenges or needs we should be aware of? (e.g. dyslexia, comprehension difficulties)

 

Question 22 of 25

Is there anything else you would like us to know to help personalize your child’s library?

Question 23 of 25

Consent: 

I give permission for The Reader’s Lab to collect and use this information to create a personalized library for my child.

A

I consent

B

I don't consent

Question 24 of 25

Signature

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Question 25 of 25

Date

Confirm and Submit