DVCC Summer Literacy Lab – Intake Form

Students first name

Students last name

Students Birthday

Month

Day

Year

Age

2026-2027 School Attending

Students grade entering Fall 2026

Any food allergies?

Parent Information

Parent first name

Parent last name

Phone

Email

2nd Emergency Contact Name:

Emergency Contact Phone Number:

Home language:

Photo & Social Media Consent - May we take photos of your child during program activities for use in promotional materials and social media? Faces may be shown.

Yes

No

Program Agreement - I understand that participation in the Summer Reading Program is free and voluntary. I agree to help my child track their reading progress and return materials on time.

yes

Commitment Check - I understand that for my child to participate, as parent/guardian, I must stay on site for the full 2 hours.

Student reading information

Has your child been identified as an English language learner (ESL) at their school?

yes

no

Does your child receive any additional services (i.e. speech, reading specialist, etc.)?

Is your child below, on, or above grade level indicated by their teacher?

Does your child enjoy reading?

Yes a lot

Sometimes

Not really

Not at all

What is the biggest challenge your child has with reading? (check all that apply)

Sounding out words

Reading smoothly

Understanding what they read (comprehension)

Reading Stamina/Staying interested

In a few words, please describe your child’s reading needs:

Please describe your child’s reading habits and routine at home (i.e. how long do they read, does a parent read aloud, where do they read, etc).

What topics interest your child?

Which activities interest your child? (click all that apply)

End-of-Summer Grand Prize Preference (All students who attend 6 of the 8 sessions automatically get one of the following prizes at the end of the summer)

Is there anything else you would like to tell us about your child or your family?