Date:

Title of Program:

Type of Program  (select only one):

Assignment Alert Programs
Book Collections/Kits
Book Discussion Groups
Community Reading Projects
Delivery to Schools
Large, Systemwide Initiatives
Library Card Campaigns
Library Cards for Educators/Schools
Public Library Visits to Schools
School Visits to the Public Libraries
Publicity (joint newsletters, blogs, etc.)
Special Events
Summer Reading Programs & Lists
Tutoring/Student Success Programs

Intended Grade Level of Participants (check all that apply):

Preschool
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12

Description of Program:

Name of Contact Person:

Title of Contact Person:

School/Library Name:

Mailing Address:

Phone:

Email Address:

URL of Library:

URL of School:

Citation for any presentation(s) or article(s) reflecting partnership: