First Name	Last  Name
Day Phone	Evening Phone
Your E-mail	Other Phone

Street Address

City, State, ZIP

How did you hear about us (pick one):
Brochure/Flyer/Poster
Church:      
        Which church?      
College/University:      
        Which college?     
Corporation/Business:
        Which business? 
Expo/Fair:
        Which expo/fair?   
Event/Fundraiser: 
        Which event?         
Friend/Family
Internet:
        Which website?    
Library:   
        Which library?       
Literacy Connection Newsletter
Literacy Connection Staff or Board
Literacy Connection Student
Newspaper: 
        Which newspaper?  
Phone book
Radio
School (High school/Grade school):
         Which school?     

Will you be attending our next orientation session?
 Yes
 No

Do you have any questions or comments for us?