2013 Chelmsford Community Read-In April 8th – April 12th

I would like to participate in the 2013 Community Read-In!

Name ___________________________________________

Business ________________________________________

Address _________________________________________

Email address________________________________________________________________

Phone _______________________________ Preferred form of contact: phone / email

My preference is for grade (please circle grade preference) :

CHIPS Pre-K (Westlands Only) K 1 2 3 4 5 6

No preference _________

Particular class requested (if any): _______________________________

My preference is to read at the following school(s):

Byam ___ Center ___ Harrington ___ South Row ___ Westlands(Chips) ___McCarthy___

Parker___ No preference __________

The best day for me is:

April 8 ____ April 9____ April 10 ____ April 11 ____ April 12 ____

The best time of day for me is:

Morning ____ Afternoon ____ Any specific time frame better? ___________________

Number of classes I would like to read to: _______

Are you a High School Student: Yes* / No If yes, do you have transportation: Yes / No

* If yes, what specific time is preferred (please do not indicate by block only) _________

Please email chelsmfordreadin@gmail.com or return form to:

Tara Trainor, 25 Middlesex St, North Chelmsford, MA 01863

By March 9, 2012. Thank you!!

---------------------------------------------------------------------------------------------------------------- For Coordinator’s Use Only:

School _____________ Grade ____ Teacher ________________ Room ____ Date __________Time_____

School _____________ Grade ____ Teacher ________________ Room ____ Date __________Time ____

School _____________ Grade ____ Teacher ________________ Room ____ Date _________Time______