Print out this form and mail to:
The Ferst Foundation for Childhood Literacy
P. O. Box 1327
Madison, GA 30650

Please complete an entire form for each child.

Child's First Name____________________________     Child's Last Name_______________________________

Child's Date of Birth _________________

Sex: ____M  ____F

Child's Home Address__________________________________

________________________ GA ________________________
                    City                                                              Zip

Parent/Care Giver's First Name_________________________     Last Name_______________________________

Parent/Care Giver's Phone #____________________________

Parent/Care Giver's Address_____________________________

__________________________ GA _______________________
                    City                                                              Zip

The Parent's Guide sent with the first book is available in _____ English or ____Spanish (Please check next to language you prefer)

This child is a resident of a participating county   _______________________________ (Please list your county)

__________________________________
Signature of Parent or Care Giver