Please complete this form if you would like to host training.
Zip Code: Phone (main): Email:
Please check here if you would be willing to participate in a follow-up questionnaire.
Please check this box if you are interested in learning about future workshops and programs.
Workshops are available at a number of locations on different days and times. You may choose a location and time from the calendar at http://dallaslibrary.org/ecrr/ecrr-cal.htm.
Location chosen from calendar: Date from calendar:
North Dallas West Dallas Central Dallas Southeast Dallas Northeast Dallas
Do you prefer (choose one):
Weekday Weekend Do you prefer (choose one): Mornings Afternoons Evenings
Will you need childcare for children ages 5 and under while you attend a workshop?
yes no
How may children will attend with you?:
How many children do you have in the home and what ages?
Ages:
Number of Boys:
Number of Girls:
Early Talkers (birth to age two) Talkers (ages two and three) Pre-Readers (ages four and five)
Ethnic Group:
African American Asian/Pacific Islander Hispanic/Latino Native American White Other ethnic group:
Will you need Spanish language assistance?
