Child's Name _____________________________________________________________________

Grade and School __________________________________________________________________

Address ___________________________________________ Phone* _______________________
(*Required: Participants will be contacted by phone to confirm reading times.)

Parent/Guardian name, (address, phone if different than child's)____________________________________

How did you hear about this program?
Teacher | Librarian | Friend | Parent | TV | Newspaper

Does the child have:
- any fear or apprehension around animals, especially dogs? ____________

- a dog at home? ___________

Please provide any additional information the reading dog therapy team might need:
__________________________________________________________________________________

Please check the library location you wish to attend and indicate your first and second choice for a time slot. Then return this signed form to any Milwaukee Public Library at least two weeks prior to the start of the program at the location you've chosen.

I, _____________________________________________________ agree that my child will be a
                        (signature of parent or guardian)

member of the Read to Rover program and will attend each week of the four-week program.

Date application received at library ___________________________

Sponsored by Milwaukee Public Library and the Wisconsin Humane Society.

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