211/United Way Registration

(* denotes required fields)

Today's Date:*

First Name:*

Last Name:*

Address:*

Address 2:

City:*

State:

CONNECTICUT

ZIP Code:*

County:*

Home/Mobile Phone:*

Email:

Language(s) spoken at home:*

How many children do you have at home?

None (I'm pregnant with my first)

3 or more

In my home, we have this number of books:*

20 or more

10-19

1-9

None

At what hospital will your child be born?*

Hospital Name:*

Are you currently receiving prenatal care?*

Yes

Where are you receiving prenatal care?*

If you have children at home, how often are you reading together?*

Daily

4-6 times a week

1-3 times a week

At least 1 time a week

Never

How comfortable do you feel reading to your baby?*

Very comfortable

Comfortable

Uncomfortable

Very uncomfortable

Is there anything we at Read to Grow could do to make it easier or more fun to read with your baby?

Before submitting your request, please make sure all required fields are completed.

Once you click “Submit,” you should see a message that says “Thank you for signing up! Your form has been submitted, and your free board book is on its way.” This confirms that your request went through.

If you do not see the “Thank you” message, your request was not submitted successfully. Please double-check the form and try again.

Thank you for your time and care in completing the request!

211/United Way Registration

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