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2. Dolly Parton's Imagination Library Official Registration Form

   Privacy Statement: This information will not be used for any purpose other than to register your child for the Imagination Library program.

4. Child's Full Name*
6. Child's Date of Birth *
   Child's Date of Birth

   child must be under 5 years old

7. Gender

   1. Male
   2. Female

   This information helps secure grant funding

8. Race
   -- Select One --American Indian/Alaska NativeAsianBlack/African AmericanHispanic/LatinoNative Hawaiian/Other Pacific IslanderWhite

   This information helps secure grant funding

9. County of Residency*
   -- Select One --Gaston CountyLincoln County
11. Child's Home Address*
13. City*
14. State*
15. Zip Code*
17. Mailing Address

    use if different from home address

19. City
20. State
21. Zip Code
23. Phone Number
25. Parent/Guardian's Full Name*
27. Parent/Guardian's Email Address
29. Parent/Guardian Signature *
Leave This Blank:


31. Submit

* indicates a required field