Child Registration Form

Child Registration Form

Fill out this form to register your child for the Dolly Parton's Imagination Library Program. Your child must be under age 5 and a resident of Desha, Drew, Cleveland or Lincoln County to complete this online form.
1st Child's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Gender
2nd Child's Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Gender
Address*

Home Address

Mailing Address (Even if the same)

CityState

Zip Code
E-mail*
example@example.com
Mobile Number

Area CodePhone Number
Phone Number*

Area CodePhone Number
Work Number

Area CodePhone Number
Parent's Name*
Full Name
Should be Empty: