Contact Name:

Title/Position: Teacher Parent Principal Asst. Principal Administrator Literacy Coordinator Other

If "Other", please specify:

Phone:

Fax:

E-mail:

School:

Address:

City:

State:

Zip:

Cross Streets:

Principal:

Ass't Principal:

District:

Grades:

Calendar:

Are you a Title 1 school?Yes   No

Total number of students:

Percent on Free or Reduced Lunch:

What other volunteer literacy programs are in your school?:

Nearest BookPALS Branch: Please choose one Arizona Coachella Valley Florida Las Vegas Los Angeles/Orange Co. Minnesota New York Other