Child's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

M/F? *

Male

Female

Ethnicity *

African American

Hispanic

Asian / Pacific Islander

White / Caucasian

Other

More than one child under the age of 5-years old?

Yes

No

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

M/F?

Male

Female

Ethnicity

African American

Hispanic

Asian / Pacific Islander

White / Caucasian

Other

Child's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

M/F?

Male

Female

Ethnicty

African American

Hispanic

Asian / Pacific Islander

White / Caucasian

Other

Child's Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Caregivers Name *

First Name

Last Name

Phone *

*Please provide a valid phone number so that we can contact you if your child's book is lost or returned. We do not share phone numbers/email addresses with third parties.

(###)

###

####

How did you learn about us?

Online / Social Media

Library

Low Country Food Bank

First Steps

Pediatrician

TV

MUSC

Roper St. Francis Hospital

Trident Literacy

Friend