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2. Tell Us About You:
4. Name of Organization*
5. Site Address*
   Location where the Readmobile would visit.
7. Contact Person *
8. Position*
10. Email Address*
11. Phone Number*
13. On-Site Contact Person (if different from above)
15. Email Address:
16. Phone Number
18. What are you hoping to achieve by having the Readmobile Visit*
20. How can the Readmobile support you/your organization?*
24. Readmobile Visits
26. Visit Timeframe*

    1. Weekly for 12 Weeks

    1. Weekly for 6 Weeks

    1. Monthly

    1. One Time Visit
28. Preferred Start Date and Start Time*
    Preferred Start Date and Start Time

    Preferred Start Date and Start Time
29. Preferred Day of the Week*
31. Preferred Length of Visit*
    -- Select One --45 Minutes1 Hour90 Minutes2 HoursOther
32. Other*
34. How many children ages 0-5 could we expect to see during a visit?*
35. How many parents/caregivers could we expect to see during a visit?*
37. How will you help promote the Readmobile?*

    1. Flyer

    1. Email Blast

    1. Other
38. Other*
40. To what extent would you want to be/able to be involved with Readmobile visits?*
42. The Readmobile is very large - 32 feet long by 11 feet high by 7 feet wide. Does your location include:

    Check all that apply

    1. A level spot for parking
    2. Ability to pull up to a sidewalk and park
    3. A safe area in your parking lot for the Readmobile to park
    4. Adequate parking for families
    5. A public transit stop within walking distance
44. Is there any other information about your site that is relevant to bringing the Readmobile?
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field