Braille Book Enrollment

Braille Imagination Library Books

Child's First Name:(Required)

Child's Last Name:(Required)

Child's Birthdate (mm/dd/yyyy):(Required)

Gender(Required)

Male

Female

Check one:(Required)

I'm the child's parent

I'm the child's legal guardian

I am a third party

If you are the child’s legal guardian, please indicate whether you are a grandparent, aunt/uncle, foster parent, etc:

If applicable, please provide the name of the agency or organization providing support services for your child:

Please check one of the following boxes:(Required)

My child is a braille reader or is likely to use braille as his or her future reading medium.

I, the parent or legal guardian of the child being registered, am a braille reader.

Your Title (Mr./ Ms./ Mrs.):(Required)

Your First Name:(Required)

Your Last Name:(Required)

Address:(Required)

Street Address (books will be mailed to this address) Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email:(Required)

(correspondence and updates will be sent via email)

Phone:(Required)

(In case there is a problem with email or book delivery)