Re-Imagine Book Club

Re-imagine Book Club

Inspiring a Love of Reading—One Book, One Challenge, One Child at a Time
Parent's Name*

First NameLast Name
Parent's Email*
example@example.com
Address*

Stret Address

Street Address Line 2

State / Province

City, Postal / Zip Code
Parent's Phone Number*
Please enter a valid phone number.
Child's Name*

First NameLast Name
Date Of Birth

MonthDayYear
Date
Child's School*
Grade Level*
Race (this is for statistical data only)

WhiteBlack/ African AmericanHispanic or LatinoAsianIndigenous/Native AmericanTwo or more racesOtherI don't want to answer

Participation Agreement (By joining this Re-imagine Book Club, I agree to:)*

	I agree to:	I do not agree to:
Submit grades each -quarter
Participate in monthly reading challenges
Attend at least one event per quarter
Promote kindness, inclusion and love of learning
Read at least 20 minutes each day

Media Release Consent:

By joining our bookclub, I give permission for photos or videos of my child participating in book club activities to be used by Re-imagine Communities for promotional and educational purposes, including but not limited to print, online, and social media. I understand that my child’s name or personal information will not be shared without additional consent.

I acknowledge that I will not receive compensation for the use of these images or recordings and that I waive any right to inspect or approve the final materials. I also agree not to hold Re-imagine Communities liable or pursue legal action for the use of these photos or videos.
Signature of Parent/ Guardian

Clear
"By signing above, you acknowledge that you have read, understood, and agree to the terms and conditions outlined."
JOIN OUR READING CHALLENGE CLICK HERE
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