Sign your child up to receive a free book every month, delivered to your door.
Child’s First Name *
Last name *
Address *
Date of Birth *
Gender * BoyGirl
Parent / Guardian First name *
Gender MaleFemaleOther
Age Group * Under 2021-3031-4041+
Aboriginal
Referring agency (i.e. MCHN, Baptcare)
Torres Strait Islander
Email Address *
Phone Number *
Main language spoken at home
Does your child attend:
Preschool
Kinder
Playgroup
Formal Childcare
How did you find out about this programme?
Show / Event
Radio
TV
Internet / Social Media
Does your child attend a supported playgroup or formal childcare? * YesNo
How often does your child attend the local library? * WeeklyMonthlyOnce every few monthsRarely
How often do you share a book with your child and for how long?
Daily2-3 times a weekWeekly2-3 times a monthMonthlyEvery few months
Less than 5 minutes5-10 minutes10-20 minutesMore than 20 minutes
Approximately how many books do you have at home?
On a scale of 1-10, how comfortable do you feel sharing a book with your child? (1 being not very comfortable, 10 being very comfortable) 12345678910
Which of the following do you have access to?
SMS/Text Message
Smart Phone
Computer/Laptop with internet
Email
Facebook
Tablet
How did you find out about this program?
As the legal parent or guardian, I give my permission for the child to be enrolled in the programme and for Communities for Children, St Luke’s Anglicare Bendigo and its agencies to keep this information for the purposes of the Imagination Library programme.
I agree *
4 + 2 = ?Please prove that you are human by solving the equation *
