Name of Organization:

Please provide the following contact information:

First Name
Last Name
Title
Shipping Address (No PO Boxes)
Shipping Address (cont.)
City
Zip/Postal Code
Work Phone
E-mail

What most accurately describes your program. Select all that apply.

After school               Child care                 	Community center                     
Home visits               Library                    	Parent education           
School-based             Shelter                    	Tutoring/Mentoring                             

Health services	     Preschool/Early education  	Other

Are you a Title 1 school?

Yes No

If no, what percentage of children in your program who will receive books are from low-income households? Must be at least 80%.

What criteria does your program use to determine the economic need of the children you serve?  (e.g. Free or reduced-price lunch).

Has your program ever received a grant from a First Book Advisory Board?

Yes No

If yes to the above, what is your Recipient Group number?

Number of children you serve who are Pre-K.

Number of children you serve who are K through 1st grade.

Number of children you serve who are 2nd through 3rd grade.

Number of children you serve who are 4th through 6th grade.

Number of children you serve who are7th grade or higher.

Total number of children in all age groups.