*1.School Name(Required.)

*2.Your Name & Title(Required.)

*3.Email and/or Phone Number(Required.)

*4.How many students are currently enrolled in grades K-3?(Required.)

*5.What percentage of your students are currently enrolled in the free or reduced lunch program?(Required.)

*6.Can you agree and follow the expectations listed below?

a. All teachers in grades K-3 must participate in the program. We do not want any classes from these grades left out of the program and therefore not receiving books.

b. Teachers must place 1 order per month. All teachers MUST place their own book orders each month, for their classroom and their classroom only. We do not allow for one teacher to place an order for multiple classrooms, the whole grade, etc. Queen City Book Bank staff cannot place the orders for you.

c. A contact person at each school will be required. This will be a school staff member who is not a teacher that is willing to help with communication and execution of the responsibilities. This could be the school resource coordinator, a reading specialist, the school librarian, or another staff member.

d. Teachers must be willing to complete 2 surveys per school year.

e. Principal must be aware of and supportive of the program.

f. School must be willing to help with unloading the boxes of books on delivery day, once per month.(Required.)

YesNo

*7.Please share how this program would benefit your students?(Required.)