Summer 2013 Writing Buddies Application (Little Buddies)

1. Summer 2013 Writing Buddies Application (Little Buddies)

2. Deadline for applications: Wednesday, May 22, 2013

3. Parents/Guardians of students who will be in grades 4-6 in the fall may apply to have their child participate in the program on a first-come, first-serve basis, with priority given to Lafayette residents and students who attend Lafayette schools. Apply early!

4. Child's Name:*

5. Grade in fall:*

6. Age:*

7. Gender:*
   1. Male
   2. Female

8. School (fall):*

9. Parent/Guardian's name(s)*

10. Street Number*

11. Street Name*

12. Street Type

13. Apt #

14. City*

15. State*

16. Zip*

17. Home phone:*

18. Daytime/Emergency phone:*

19. Email address:

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

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

22. If yes, what year did your child participate and in which program?

23. Please confirm your child's availability. Your child is expected to attend ALL sessions unless the Reading Buddies coordinator is notified in advance.*
    1. Yes, my child can participate on Tuesdays from 10-11 am, June 4 through July 23 (no meeting July 2)

24. List here any dates that your child will not be able to attend. If your child will miss 3 or more meetings due to vacation or camp, please consider waiting until next summer to sign up for Writing Buddies.

25. Please have your child complete this paragraph: I'd like to participate in Writing Buddies because*

26. My child's writing level is:*
    -- Select One --below grade levelat grade levelabove grade levelI'm not sure

27. In general, my child is:*
    -- Select One --Very outgoingGenerally outgoing but shy at first when meeting new peopleMay take several meetings to warm up to new peopleVery shy

28. In general, my child:*
    -- Select One --Focuses on 1 activity at a time for a short timeFocuses on 1 activity at a time for a long timeLikes to be engaged in several activities at once and/or likes to change activities frequently

29. In general, how does your child feel about school:*
    -- Select One --Doesn't enjoy schoolIt depends on the dayEnjoys schoolReally loves school

30. How does your child feel about writing:*
    -- Select One --Truly enjoys writingSometimes enjoys writingIs ambivalent about writingIs a very reluctant writer

31. By submitting this Writing Buddies application, I agree that (check all boxes)*
    1. I have read the Writing Buddies brochure (please find link below).
    2. I am aware of the dates and requirements of the program, and I agree to notify the Reading Buddies Coordinator if my child is unable to attend a meeting.
    3. I agree to help my child participate fully in the program to the best of my ability, including making sure that she/he arrives on time for each session.

32. Writing Buddies Brochure (you must read before submitting this application)
    Writing Buddies Brochure

33. 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 use of the materials.*
    1. Yes, I give the library permission to use photos of my child in publicity materials and agree to the above photo release statement.
    2. No, I do NOT give the Lafayette Public Library permission to use photos of my child.

Leave This Blank:


34. 1. Receive email copy
35. Email address

36. Submit

* indicates a required field