Reading Room Form:
A Reading Room for Kids and one for Adults
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail - Your reading room invitation will be sent here.
example@example.com
Which reading room do you wish to join?
Anita's Imagination Station for Kids
Brain Bash for Adults
Is this your first year to join the reading room?
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other (Please specify...)
Which form of communication?
Please verify the reading room you wish to join.
I am a kid between ages 5 and 11 years old.
I am an adult ages 18 or older.
I am a parent signing up my child.
Will you be willing to recommend us?
Yes
Maybe
No
Please give reference of two people whom you feel would be great guest readers:
Full Name
email address
Anita's Imagination Station
1
2
My Products
prev
next
( X )
Anita's Imagination Station Donation
Anita's Imagination Station Reading Room for Kids One year of adventure.
$
15.00
Quantity
1
2
3
4
5
6
7
8
9
10
First Time Venture - Reading Room- Free
First venture is free! Welcome to the Reading Room!
$
Free
Brain Bash Reading Room
Donation for one calendar year per family
$
25.00
one adult
two adults - family
three adults- family
Item subtotal:
$
0.00
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit
Should be Empty: