Spring 2013 Little Buddies Application

1. Spring 2013 Little Buddies Application

2. Openings on Saturday Mornings!

3. Deadline for applications, Monday, 1/28/2013
   Parents/guardians of students in grades 1-3 may apply to have their child matched with a Big Buddy, on a first come, first served basis. Priority given to Lafayette residents, and students who attend Lafayette schools. Apply early! The coordinator will contact you within three days to acknowledge receipt of this application, and let you know if space remains in the program. Please PRINT all information clearly!

   Parents/guardians of students in grades 1-3 may apply to have their child matched with a Big Buddy, on a first come, first served basis. Priority given to Lafayette residents, and students who attend Lafayette schools. Apply early! The coordinator will contact you within three days to acknowledge receipt of this application, and let you know if space remains in the program. Please PRINT all information clearly!

4. Child's name*

5. Grade*

6. Age*

7. School*

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

9. Parent/guardian name(s)*

10. Address *

11. City*

12. State

13. Zip Code*

14. Parent/Guardian home phone*

15. Daytime Emergency Phone Number:*

16. Email address:

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

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

19. If yes, in:

20. Indicate your availability for the Spring sessions. Your child is expected to attend ALL meetings, unless the Coordinator and Big Buddy are notified in advance.*
    1. Tuesdays, 4-5pm, 2/5 through 4/30 (no meeting on 2/19 or 3/26)
    2. Saturdays, 10:15-11:15am, 2/2 through 4/27 (no meeting on 3/23 or 3/30)
    3. We are available for either sesison

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

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

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

24. Would you prefer your child to have a Big Buddy who is a *
    -- Select One --BoyGirlDoesn't matterPrevious Big Buddy if possible (name)

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

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

27. 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:

28. My 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

    1. 4
    2. 5

29. My child focuses on one activity at a time, or is 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

    1. 4
    2. 5

30. My child is reluctant about school or enjoys 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

    1. 4
    2. 5

31. My child is hesitant to join Reading Buddies or is eager to join Reading Buddies. 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

    1. 4
    2. 5

32. My child's interests are:*

33. My child's favorite books are:*

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

35. By submitting this Reading Buddies application, I agree that (check all):*
    1. I have read the Reading Buddies Informational for Parents brochure or website.
    2. I am aware of the dates and requirements of the program, and I will notify the coordinator and my child's Big Buddy if my child is 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.

36. 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
    2. No, I do not agree

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

Leave This Blank:


38. 1. Receive email copy
39. Email address

40. Submit

* indicates a required field