Readers in Training Pre-Qualification Form

Readers in Training Pre-Qualification Form

This program is brought to you by Spread the Word Nevada in partnership with United Way of Southern Nevada, Andrews Family Foundation and the Routh Family Foundation.
Did you know that reading readiness begins at birth? Spread the Word Nevada's new program, Readers in Training (RIT), is making it possible for your younger children to join in the fun!
Through this pilot program, we will serve 75 children ages 0-4 and their parents/guardians.

Your child(ren) will receive:
- Age-appropriate new books mailed monthly
- Tips and activities
- Monthly small group training & story times

This program will run for 4 months May 2022 - Aug 2022.
What school or organization provided you the flyer for this program? *
How did you hear about this program? *
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Email *
example@example.com
Cell Phone Number *

Area Code Phone Number

Contact Information
Parent/Guardian Physical Address (where you can receive packages) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Preferred method of contact (select all that apply) *

Cell Phone Email Text Messsages Mail
Will you allow STWN to send you text messages? *

Yes No

Readers In Training Agreement

We are so excited to go down this journey with you! We are going to have so much fun over the next 4 months. Please review the information below:
- I agree to engage on the private Facebook page with other families to get the most out of my experience.
- I agree to participate in the surveys and questionnaires sent out that will assess my learning, my child(ren)'s progress, and the quality of the program.
- I understand that this program is offered to families who have agreed to participate. As such, I agree to keep all information pertaining to other people in the program confidential. I will not share any photos, posts, or material outside of our private page. It is important for our families to know this is a safe place to share information.
- I agree to participate in the LIVE virtual training sessions. I will do my best to participate in all 4 sessions and understand if I cannot attend, I will contact the instructor and will watch the recording of the session on my own time.
- I agree to participate in the 4 face-to-face sessions. I understand this is where I will get to choose books for my child(ren) to keep, interact with families, and learn tips and tools to use at home. I understand that if I miss more than 2 of the face-to-face sessions, I will be removed from the program.
- I agree to have fun.
Do you agree to the above program requirements? *

Yes No

Media/Photo Release
I hereby grant Spread the Word Nevada permission to use my name, quotation and/or my likeness in a photograph or video in any and all of its publications, including website entries, without payment or any other consideration.

I understand and agree that these materials will become the property of Spread the Word Nevada and will not be returned.

I hereby irrevocably authorize Spread the Word Nevada to edit, alter, copy, exhibit, publish or distribute this photo and/or my quote or video for purposes of publicizing Spread the Word Nevada’s programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness or quote appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph, video or quotation.

I hereby hold harmless and release and forever discharge Spread the Word Nevada from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I am at least 18 years of age and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.
I agree to have my photo taken and used for Spread the Word Nevada marketing purposes *

Yes I do not mind if my photos and/or videos are used to help promote the program No I would prefer not to use my photos or participate in video footage
My signature affirms that all information is true and correct to the best of my knowledge. *

Clear

Who should we contact in the event of an emergency?
Name *

First Name Last Name
Email Address *
example@example.com
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Thank you for the information!

Please hit submit and check your email for confirmation
Should be Empty:

Readers in Training Pre-Qualification Form

Tell Us About Your Children

Contact Information

Household Information

Readers In Training Agreement

Required Virtual Training Sessions

Connectivity Questions

Media/Photo Release

Who should we contact in the event of an emergency?

Thank you for the information!