Frequently Asked
REGISTRATION REGISTRATION FORM FORM
questions
This Thisinformation informationwill willonly onlybe beused usedfor forUnited UnitedWay’s Way’sliteracy literacy program. program.Please Pleasecomplete completeone oneform formper perchild. child.Print Printclearly: clearly:
Is my child eligible? Yes, if born after 1 Jan 2011 and currently residing in the Glenelg Shire, 3285, 3286, 3292, 3301, 3302, 3303, 3304, 3305, 3309, 3310, 3311, 3312, 3315 Do I have to pay? No; thanks to the support of Portland Aluminium and United Way, Dolly Parton’s Imagination Library is FREE! How do I sign up my child? Complete this form and post it! When will I receive my books? Eight to ten weeks after your registration form has been received, books will begin arriving at your home and will continue monthly until your child turns five*.
ChIld’S ChIld’SFIRST FIRSTNAME NAME
does doesyour yourchild childattend attendaasupported supportedplaygroup playgroupor or (CIRClEONE) ONE) formal formalchildcare? childcare?(CIRClE YY / / NN how howoften oftendoes doesyour yourchild childvisit visitthe thelocal locallibrary? library? (CIRClE (CIRClEONE) ONE)
ChIld’S ChIld’SlAST lASTNAME NAME ChIld’S ChIld’SBIRTh BIRThdATE dATE
Weekly Weekly // ddAAYY
// MMOONNT Thh
YYE EAARR
(CIRClEONE) ONE) M ChIld’S ChIld’SGENdER GENdER(CIRClE M / / FF
Monthly Monthly
Once Onceevery everyfew fewmonths months
Rarely Rarely
how howoften oftendo doyou youshare shareaabook bookwith withyour yourchild childand and for forhow howlong? long?(CIRClE (CIRClEONE ONEFOR FORPAR PARTS TS1 1&&2)2) 1.1. daily daily 2-3 2-3times timesaaweek week Weekly Weekly 2-3 2-3times timesaamonth month Monthly Monthly Once Onceevery everyfew fewmonths months
STREET STREETAddRESS AddRESS
2.2. less lessthan than5mins 5mins 5-10 5-10mins mins 10-20mins 10-20mins
SUBURB SUBURB
More Morethan than20mins 20mins
STATE STATE
Approximately Approximatelyhow howmany manychildren’s children’sbooks booksdo doyou you have haveatathome? home?
POSTCOdE POSTCOdE
Parent Parent/ /GUarDIan GUarDIanDetaIls DetaIls TITlE TITlE
On Onaascale scaleofof11to to10, 10,how howcomfortable comfortabledo doyou youfeel feel sharing sharingaabook bookwith withyour yourchild? child? (CIRClE (CIRClEONE) ONE)
FIRST FIRSTNAME NAME
11
lAST lASTNAME NAME
22
33
44
55
66
77
(NOT (NOTvERY vERYCOMFOR COMFORTABlE) TABlE)
GENdER GENdER(CIRClE (CIRClEONE) ONE)
MM / / FF
88
99
1010
(vERY (vERYCOMFOR COMFORTABlE) TABlE)
Which Whichofofthe thefollowing followingdo doyou youhave haveaccess accessto? to? (TICK (TICKWhERE WhEREAPPlICABlE) APPlICABlE)
*Whilst the program is supported in your community.
AGE AGE(CIRClE (CIRClEONE) ONE) less lessthan than20 20
21-30 21-30
31-40 31-40
Over Over40 40
Aboriginal Aboriginal/ /Torres TorresStrait StraitIslander Islander/ /BOTh BOTh/ /Not NotApplicable Applicable
SMS/Text SMS/TextMessages Messages
Email Email
Smart SmartPhone Phone(i.e (i.eiPhone) iPhone)
Facebook Facebook
Computer/laptop Computer/laptopwith withInternet Internet
Tablet Tablet(i.e (i.eiPad) iPad)
(CIRClE (CIRClEONE) ONE)
MOBIlE MOBIlE EMAIl EMAIl
PRIMARY PRIMARYlANGUAGE lANGUAGESPOKEN SPOKENAT AThOME hOME
how howdid didyou youfind findout outabout aboutthis thisprogram? program?
“You “Youunderstand understandthat thattotoregister registera achild childwith withthe theImagination Imaginationlibrary libraryyou youMUST MUST BEBEThE ThEPARENT PARENTOR ORlEGAl lEGAlGUARdIAN GUARdIANofofthat thatchild. child.ByBycompleting completingthis thisform, form,you you consent consenttotothe theuse useofofyour yourpersonal personalinformation informationbybyUnited UnitedWay WayAustralia Australiaand anditsits program programpartners: partners:totoprocess processyour yourregistration, registration,totocontact contactyou you(including (includingbybyemail email and andtext textmessage) message)about aboutthe theprogram programand andour ourservices, services,totosend sendyou youelectronic electronic commercial commercialcommunications communicationsand andfor forinternal internalpurposes. purposes.United UnitedWay WayAustralia Australia protects protectsthe theprivacy privacyand andsecurity securityofofinformation informationprovided providedbybyyou youininaccordance accordancewith with our ourPrivacy PrivacyPolicy Policyaccessible accessibleat:at:http://unitedway.com.au/privacy-policy. http://unitedway.com.au/privacy-policy. ””
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What do I do after I sign up? Read to your child anywhere, anytime United Way Glenelg United Way Glenelg is a non-religious and non-political organisation that is working to improve education in the Glenelg region. Questions? Email is at mail@unitedwayglenelg.com.au go to our website www.unitedwayglenelg.com.au or contact us on 0410 513 305
This Thisprogram programaims aimstotoincrease increaseyour yourchild’s child’sreading, reading,can can you youtell tellus usabout aboutyour yourchild’s child’scurrent currentreading readingactivities: activities:
(SIGN (SIGNhERE) hERE)
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(dATE) (dATE)