Registration Form
YOUNG HEARTS READY READERS BOOK CLUB
Youth Member
First Name
Last Name
Parent/Gaurdian
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Reading Level?
Above current grade level
At current grade level
Below current grade level
Any Current Reading Disabilities?
Dyslexia
Dysgraphia
Dyscalculia
Auditory Processing Disorder
Nonverbal Learning Disorder
Acquired Dyslexia
Phonological Dyslexia
None
Other
Current Allergies
Food Allergy
Seasonal Allergy
Indoor Allergy
Asthmatic Allergies
Medicinal Allergies
Other
Please list all allergies.
GRADE LEVEL
Second
Third
Fourth
Fifth
AGE
Submit
Should be Empty: