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RosterID
Form Type-Preset
LB
RE
RI
LBR
RER
RIR
In which program would you like to enroll this student?
Lunch Bunch
The Reading Express
Reading Intervention
Lunch Bunch Enrollment Form
The Reading Express Enrollment Form
Reading Intervention Enrollment Form
Student Information
Student's First Name
Student's Last Name
Date of Birth
Grade
Please select...
Pre-K
K
1
2
3
4
5
Gender
Please select...
Male
Female
School
Please select...
Cunningham Elementary
Daily Elementary
Mark White Elementary
Milne Elementary
Neff Elementary
Ogden Elementary
Piney Point Elementary
Ross Elementary
Valley West Elementary
School (The Reading Express)
Please select...
New Hope Housing
San Francisco Nativity Academy
St. Luke's UMC Gethsemane
Woodchase Park
School (Lunch Bunch)
Please select...
Cunningham Elementary
Daily Elementary
Fondren Elementary
Mark White Elementary
Milne Elementary
Neff Elementary
Ogden Elementary
Piney Point Elementary
Ross Elementary
Valley West Elementary
Ethnicity
Please select...
Black or African American
Asian
Hispanic
White
Other
Language(s) spoken at home
Attending Bilingual Classes?
Yes
No
Special Ed?
Yes
No
Do you receive SNAP or TANF benefits?
Yes
No
HISD Student ID
Lives with
Please select...
Mother
Father
Both Parents
Other
Lives with (other)
Any allergies?
Yes
No
Any medical conditions?
Yes
No
Please describe allergies or medical conditions
Getting to Know Your Child
Help us learn more about your child to set the stage for a successful year.
My child's favorite things
Toy
Book
Color
Movie
Activity
Other
Is there anything your child struggles with that you would like us to know about?
Please list two reading goals you would like to set for your child this year
If your child does not read or is not read to regularly at home, please explain why.
Examples: does not like to read, other activities, lack of books at home, time, etc.
Does your child own any books?
Yes
No
About how many books does your child own? (Estimate)
Please list any materials or assistance you may need to help your child/children in reading at home.
Parent/Guardian Information
Parent/Guardian First Name
Parent/Guardian Last Name
Relationship to student
Number in Household
Please select...
2
3
4
5
6
7
8
9
10+
Single Parent?
Yes
No
Parent's Highest Grade Completed
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
GED
Some College
College
Master's
Student Address - Street
Student Address - City
Student Address - Zipcode
Parent/Guardian Email
Primary Contact #
Can Literacy Now contact you?
Yes
No
Place of employment
We communicate through the Remind app. You will receive an invitation to join. Please accept the invitation once received.
Preferred language
Please select...
English
Spanish
Other
Preferred Language (Other)
Do you have a library card?
Yes
No
Would you like to participate in our parent advisory board?
Yes
No
Income Information
What is your income amount?
Annual - $0-$15,650 / Monthly - $0-$1,304
Annual - $15,651-$26,050 / Monthly - $1,305 - $2,170
Annual - $26,051 - $41,700 / Monthly - $2,171 - $3,475
Annual - $41,701 or higher / Monthly - $3,476 or higher
Income Information
What is your income amount?
Annual - $0-$17,600 / Monthly - $0-$1,466
Annual - $17,601-$29,300 / Monthly - $1,467 - $2,441
Annual - $29,301 - $46,900 / Monthly - $2,442 - $3,908
Annual - $46,901 or higher / Monthly - $3,909 or higher
Income Information
What is your income amount?
Annual - $0-$19,550 / Monthly - $0-$1,629
Annual - $19,551-$32,550 / Monthly - $1,630 - $2,712
Annual - $32,551 - $52,100 / Monthly - $2,713 - $4,341
Annual - $52,101 or higher / Monthly - $4,342 or higher
Income Information
What is your income amount?
Annual - $0-$21,150 / Monthly - $0-$1,762
Annual - $21,151-$35,200 / Monthly - $1,763 - $2,933
Annual - $35,201 - $56,300 / Monthly - $2,934 - $4,691
Annual - $56,301 or higher / Monthly - $4,692 or higher
Income Information
What is your income amount?
Annual - $0-$22,700 / Monthly - $0-$1,891
Annual - $22,701-$37,800 / Monthly - $1,892 - $3,150
Annual - $37,801 - $60,450 / Monthly - $3,151 - $5,037
Annual - $60,451 or higher / Monthly - $5,038 or higher
Income Information
What is your income amount?
Annual - $0-$24,250 / Monthly - $0-$2,020
Annual - $24,251-$40,400 / Monthly - $2,021 - $3,366
Annual - $40,401 - $64,650 / Monthly - $3,367 - $5,387
Annual - $64,651 or higher / Monthly - $5,388 or higher
Income Information
What is your income amount?
Annual - $0 - $25,850 / Monthly - $0 - $2,154
Annual - $25,851 - $43,000 / Monthly - $2,155 - $3,583
Annual - $43,001 - $68,800 / Monthly - $3,584 - $5,733
Annual - $68,801 or higher / Monthly - $5,734 or higher
I hereby grant permission for Literacy Now to photograph, interview or videotape my child. It is my understanding that this photograph/interview/taping or portions thereof may be used for public view (newspaper articles, printed promotional materials, slide shows, television programs or on our website). I agree to allow my child to participate in programs run by Literacy Now without financial remuneration. I understand that by signing below, I release any photographer, interviewer, Literacy Now board member or staff person from any future claims, as well as from any liability arising from the use of said interview, photograph, video or printed material.
I consent to release to Literacy Now (14781 Memorial Drive, # 25, Houston, TX 77079) information related to the child’s health, including allergies and medication needs. Consent will terminate on: 7/31/2021
Contact Information