Fall 2012 Little Buddies Application: Deadline Sunday, October 14, 2012

1. Fall 2012 Little Buddies Application

2. Apply soon! Kids are assigned a Big Buddy on a first-come, first-served basis, with priority given to Lafayette residents and students who attend Lafayette schools. Deadline for applications is Sunday, October 14, 2012.
   Please be sure to read the Informational Brochure (find the link below at bottom of this application) for Little Buddies before registering your child.

   Please be sure to read the Informational Brochure (find the link below at bottom of this application) for Little Buddies before registering your child.

3. Child's name*

4. Grade*

5. Age*

6. School*

7. Male or Female?*
   1. Male
   2. Female

8. Parent/guardian name(s)*

9. Address *

10. City*

11. State

12. Zip Code*

13. Parent/Guardian home phone*

14. Daytime Emergency Phone Number:*

15. Email address:

16. What language(s) does your child speak at home?*

17. Has your child participated in Reading Buddies at the Lafayette Public Library before?*
    1. No
    2. Yes

18. If yes, in:

19. Please confirm that your child is available on Tuesdays, 4:00-5:00, from October 16 through December 11 (no meeting on November 20). Your child is expected to attend ALL meetings unless the Reading Buddies Coordinator and the Big Buddy are notified in advance.*
    1. Yes, we are available on Tuesdays, 4:00-5:00, Oct. 16 through Dec. 11

20. List here any dates that your child will NOT be able to attend:

21. To help us match the best Big Buddy to your child, please answer the following questions:

22. I would prefer my child to practice reading in:*
    1. English
    2. Both English and Spanish (subject to availability)
    3. English and another language

23. If you checked English AND another language, what is the other language?

24. Would you prefer your child to have a Big Buddy who is a *
    -- Select One --BoyGirlDoesn't matterMy child's previous Big Buddy if possible

25. If you would like your child to have a previous Big Buddy, please write their name here:

26. My child's reading level is:*
    -- Select One --Below grade levelAt grade levelAbove grade levelNot sure

27. I would like my child to have a Big Buddy because:*

28. For each of the following statements, please mark a number, between 1 and 5, based on where you feel your child falls relative to the four characteristics. This will help us choose a compatible Big Buddy:

29. Do you feel your child is shy, or outgoing, or somewhere in-between? Please choose a number between 1 and 5, with 1 being very shy and 5 being very outgoing:*
    1. 1
    2. 2
    3. 3
    4. 4
    5. 5

30. Do you feel your child tends to focus on one activity at a time, or is your child more likely to be engaged in several activities at once? Please check a number between 1 and 5, with 1 being ONE activity at a time and 5 being SEVERAL activities at a time, or somewhere in-between?*
    1. 1
    2. 2
    3. 3
    4. 4
    5. 5

31. Is your child reluctant about school or does your child enjoy school? Please choose a number between 1 and 5, with 1 being very RELUCTANT and 5 being ENJOYS SCHOOL or somewhere in-between.*
    1. 1
    2. 2
    3. 3
    4. 4
    5. 5

32. Is your child hesitant to join Reading Buddies or is your child eager to join? Please choose a number between 1 and 5, with 1 being HESITANT and 5 being EAGER or somewhere in-between.*
    1. 1
    2. 2
    3. 3
    4. 4
    5. 5

33. My child's interests are:*

34. My child's favorite books are:*

35. What else would you like us to know about your child?

36. By submitting this Reading Buddies application, I agree that (check all):*
    1. I have read the Reading Buddies Informational Brochure or website (please see link below).
    2. I am aware of the dates and requirements of the program, and I will notify the coordinator and my child's Big Buddy as soon as possible if my child will be unable to attend a session.
    3. I agree to help my child participate fully in the program, to the best of my ability, including making sure that he/she arrives on time at the beginning of the session.

37. I give the Lafayette Public Library permission to publish in print, electronic, or video format the likeness or image of my child. I release all claims against the Library with respect to copyright ownership and publication, including any claim for compensation related to the use of the materials.*
    1. Yes, I agree

38. Click below for online version of Little Buddies Informational Brochure:
    Little Buddies Information Brochure

Leave This Blank:


39. 1. Receive email copy
40. Email address

41. Submit

* indicates a required field