{"id":8493,"date":"2016-05-04T18:54:03","date_gmt":"2016-05-04T18:54:03","guid":{"rendered":"https:\/\/readtogrow.org\/es\/?page_id=8493"},"modified":"2023-12-07T17:43:35","modified_gmt":"2023-12-07T17:43:35","slug":"formulario-de-solicitud-de-libro-de-programa","status":"publish","type":"page","link":"https:\/\/readtogrow.bulldogstudios.com\/es\/como-ayudamos\/programa-de-books-for-kids\/formulario-de-solicitud-de-libro-de-programa\/","title":{"rendered":"Formulario de Solicitud de Libro de Programa"},"content":{"rendered":"<div class=\"wpb-content-wrapper\">[vc_row][vc_column]<h3 class=\"heading-horizontal\" style=\"margin:20px 0 20px 0;\"><span>Formulario de Solicitud de Libro de Programa<\/span><\/h3>[vc_column_text]\n<p style=\"text-align: center;\"><strong>Esta p\u00e1gina est\u00e1 siendo traducida al espa\u00f1ol. Gracias por su paciencia.<\/strong><\/p>\n[\/vc_column_text][vc_column_text el_class=\u00bbintro-copy\u00bb]<strong>PLEASE READ THIS ENTIRE MESSAGE:<\/strong><\/p>\n<p>This form is for programs serving children and their families in Connecticut such as: center-based child care; education and school; health care; home child-care providers and religious, nonprofit and community organizations. Read to Grow asks that any request is made at least 4\u20136 weeks in advance. If books are needed sooner, please complete the form and contact a Books for kids Coordinator at 203.488.6800.<\/p>\n<p>We provide free books to Connecticut-based programs. They can be picked up at no cost at our Branford office or delivered within the state for a $15 fee. We do not provide books out of state.<\/p>\n<p>Please plan well ahead for your book requests. It can take 4\u20136 weeks from the time of your request to the time of book delivery or pick-up.<\/p>\n<p>If you are requesting books for a family in Connecticut, please see our <a href=\"\/how-we-help\/books-for-kids\/family-book-request-form\/\">Family Book Request Form<\/a>.<\/p>\n<p>In keeping with our mission, books from Read to Grow should be given directly to children to take home and keep. We do not provide books to build lending libraries or for curricula support.<\/p>\n<p>When your books are ready, a Books for Kids coordinator will contact you to arrange your pick up or delivery.<\/p>\n<p>If you have questions, please call our office at: 203.488.6800, or email to: <a href=\"mailto:readtogrow@readtogrow.org\">readtogrow@readtogrow.org<\/a>.<\/p>\n<p><b>PLEASE FILL OUT THIS FORM. REQUIRED FIELDS HAVE ASTERISKS AND MUST BE FILLED OUT TO SUCCESSFULLY SUBMIT<\/b>.<br \/>\nAfter hitting the submit button on this form, you should immediately see a \u00abThank you!\u00bb Within a few minutes, you should also receive an emailed confirmation. If you don&#8217;t see these, please contact us at 203.488.6800.[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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campo de validaci\u00f3n y debe quedar sin cambios.<\/div><div class='ginput_container'><input name='input_79' id='input_5_79' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Tell us about yourself:<\/h3><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >(<span class=\"red\">*<\/span> denotes required fields)<\/div><div id=\"field_5_1\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_1'>Today&#039;s Date:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_1' id='input_5_1' type='text' value='05\/06\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='05\/06\/2026' aria-describedby=\"input_5_1_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_1_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_1' class='gform_hidden' value='https:\/\/readtogrow.bulldogstudios.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_32'>Official School \/ Organization Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_5_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_33'>Your Title:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_5_33' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_5'>Your First Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_5_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_6'>Your Last Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_5_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_7'>School \/ Organization Address:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_5_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_8'>Address Line 2:<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_5_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gf_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_9'>City:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_5_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_55\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-quarter gf_inline html-label gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p style=\"font-size:.9375em; line-height:1.3; margin-bottom:5px;\"><strong>State:<\/strong><\/p>\n<p>CONNECTICUT<\/p><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gf_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_17'>ZIP Code:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_5_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_4\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-quarter gf_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_4'>County:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_5_4' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='Fairfield' >Fairfield<\/option><option value='Hartford' >Hartford<\/option><option value='Litchfield' >Litchfield<\/option><option value='Middlesex' >Middlesex<\/option><option value='New Haven' >New Haven<\/option><option value='New London' >New London<\/option><option value='Tolland' >Tolland<\/option><option value='Windham' >Windham<\/option><\/select><\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_15'>Program Phone:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_5_15' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_34\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_34'>Home \/ Mobile Phone:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_34' id='input_5_34' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_16'>Email:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_16' id='input_5_16' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_68\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_68'>Alternate Email:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_68' id='input_5_68' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection just-divider field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you a state agency?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_35'>\n\t\t\t<div class='gchoice gchoice_5_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_5_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_35_0' id='label_5_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_5_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_35_1' id='label_5_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you a municipal agency?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_36'>\n\t\t\t<div class='gchoice gchoice_5_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_5_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_36_0' id='label_5_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_5_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_36_1' id='label_5_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you a Title I program?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_39'>\n\t\t\t<div class='gchoice gchoice_5_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_5_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_39_0' id='label_5_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_5_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_39_1' id='label_5_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you a Reach Out and Read (ROAR) partner?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_56'>\n\t\t\t<div class='gchoice gchoice_5_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Yes'  id='choice_5_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_56_0' id='label_5_56_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='No'  id='choice_5_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_56_1' id='label_5_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_71\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_71'>Type of organization:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_71' id='input_5_71' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='Business\/Corporate' >Business\/Corporate<\/option><option value='Community Organization' >Community Organization<\/option><option value='Early Childhood' >Early Childhood<\/option><option value='Government Agency' >Government Agency<\/option><option value='Health Care Provider' >Health Care Provider<\/option><option value='Library' >Library<\/option><option value='Philanthropic' >Philanthropic<\/option><option value='School' >School<\/option><\/select><\/div><\/div><div id=\"field_5_37\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_37'>Type of program:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_5_37' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='Professional Organization' >Professional Organization<\/option><option value='Publisher' >Publisher<\/option><option value='Vendor' >Vendor<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_5_72\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_72'>Type of program:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_72' id='input_5_72' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='Book Bank' >Book Bank<\/option><option value='Book Club' >Book Club<\/option><option value='Community Center' >Community Center<\/option><option value='Diaper Bank' >Diaper Bank<\/option><option value='Faith-based' >Faith-based<\/option><option value='Food Bank' >Food Bank<\/option><option value='Home Visitation' >Home Visitation<\/option><option value='Nurturing Families Network' >Nurturing Families Network<\/option><option value='Social Services' >Social Services<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_5_73\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_73'>Type of program:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_73' id='input_5_73' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='Center' >Center<\/option><option value='Early Head Start' >Early Head Start<\/option><option value='Head Start' >Head Start<\/option><option value='Home Visitation' >Home Visitation<\/option><option value='In-home Day Care' >In-home Day Care<\/option><option value='Preschool' >Preschool<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_5_74\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_74'>Type of program:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_74' id='input_5_74' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='Federal' >Federal<\/option><option value='Municipal' >Municipal<\/option><option value='State' >State<\/option><\/select><\/div><\/div><div id=\"field_5_75\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_75'>Type of program:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_75' id='input_5_75' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='Community Health Center' >Community Health Center<\/option><option value='Home Visitation' >Home Visitation<\/option><option value='Hospital' >Hospital<\/option><option value='Maternity' >Maternity<\/option><option value='Nurturing Families Network' >Nurturing Families Network<\/option><option value='OB\/Gyn' >OB\/Gyn<\/option><option value='Pediatric Care' >Pediatric Care<\/option><option value='Prenatal Care' >Prenatal Care<\/option><option value='Primary Care' >Primary Care<\/option><option value='School-based Center' >School-based Center<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_5_76\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_76'>Type of program:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_76' id='input_5_76' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='Friends of Library' >Friends of Library<\/option><option value='Little Free Library' >Little Free Library<\/option><option value='Public Library' >Public Library<\/option><\/select><\/div><\/div><div id=\"field_5_77\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_77'>Type of program:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_77' id='input_5_77' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='Foundation' >Foundation<\/option><option value='Fraternity\/Sorority' >Fraternity\/Sorority<\/option><option value='Hospital Auxiliary' >Hospital Auxiliary<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_5_78\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_78'>Type of program:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_78' id='input_5_78' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='Adult Education' >Adult Education<\/option><option value='Board of Education' >Board of Education<\/option><option value='College\/University' >College\/University<\/option><option value='District' >District<\/option><option value='Elementary School' >Elementary School<\/option><option value='Family Resource Center' >Family Resource Center<\/option><option value='High School' >High School<\/option><option value='Middle School' >Middle School<\/option><option value='Preschool' >Preschool<\/option><option value='PTA\/PTO' >PTA\/PTO<\/option><option value='Regional Education Service Center' >Regional Education Service Center<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_38'>If other, please specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_5_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_40\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_40'>Please describe your program:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_5_40' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_42\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_42'>Number of books you are requesting:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_42' id='input_5_42' type='number' step='any'   value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_63\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><strong>Please indicate below the number of children who will receive these books in each age range: (Age range(s) below must be completed for your order to be processed)<\/strong> <span style=\"color:#b01f30;\">*<\/span><\/div><div id=\"field_5_62\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_62'>0-2 years old:<\/label><div class='ginput_container ginput_container_number'><input name='input_62' id='input_5_62' type='number' step='any'   value='' class='small'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_65\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_65'>3-5 years old:<\/label><div class='ginput_container ginput_container_number'><input name='input_65' id='input_5_65' type='number' step='any'   value='' class='small'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_69\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_69'>6-7 years old:<\/label><div class='ginput_container ginput_container_number'><input name='input_69' id='input_5_69' type='number' step='any'   value='' class='small'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_67\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_67'>8-12 years old:<\/label><div class='ginput_container ginput_container_number'><input name='input_67' id='input_5_67' type='number' step='any'   value='' class='small'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_64\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_64'>13-15 years old:<\/label><div class='ginput_container ginput_container_number'><input name='input_64' id='input_5_64' type='number' step='any'   value='' class='small'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_70\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_70'>16-18 years old:<\/label><div class='ginput_container ginput_container_number'><input name='input_70' id='input_5_70' type='number' step='any'   value='' class='small'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_43\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_43'>Total number of children to be served:<\/label><div class='ginput_container ginput_container_number'><input name='input_43' id='input_5_43' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_19\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_19'>Please indicate any information that would help our coordinators as they prepare your request: (holidays, specific non-fiction, bilingual-English\/Spanish books, etc.):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_5_19' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_44\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_44'>How will the books be given to children to take home and keep? (All books are meant for children to take home. These are not intended for creating on-site libraries).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_44' id='input_5_44' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='For children&#039;s selection' >For children&#039;s selection<\/option><option value='With meal\/food distribution' >With meal\/food distribution<\/option><option value='With diaper\/meal distribution' >With diaper\/meal distribution<\/option><option value='During home visits' >During home visits<\/option><option value='With diaper distribution' >With diaper distribution<\/option><option value='During doctor\/medical appointment' >During doctor\/medical appointment<\/option><option value='In waiting room' >In waiting room<\/option><option value='At a special event' >At a special event<\/option><option value='For summer reading' >For summer reading<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_5_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_45'>If other, please specify:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_5_45' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_46\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_46'>If the request is for a special event, when are the books needed?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_46' id='input_5_46' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_46_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_46_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_46' class='gform_hidden' value='https:\/\/readtogrow.bulldogstudios.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_25\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_25'>How did you hear about Read to Grow?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_5_25' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose\u2026<\/option><option value='Media (TV, newspapers, etc.)' >Media (TV, newspapers, etc.)<\/option><option value='Social media \/ Internet' >Social media \/ Internet<\/option><option value='Read to Grow workshop' >Read to Grow workshop<\/option><option value='Teacher \/ childcare provider' >Teacher \/ childcare provider<\/option><option value='Home visitor' >Home visitor<\/option><option value='Library' >Library<\/option><option value='Friend \/ family member' >Friend \/ family member<\/option><option value='Vaccination clinic' >Vaccination clinic<\/option><option value='Early Steps to School Success' >Early Steps to School Success<\/option><option value='In hospital when my baby was born' >In hospital when my baby was born<\/option><option value='Prenatal clinic' >Prenatal clinic<\/option><option value='Bookmobile' >Bookmobile<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_5_28\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_28'>Hospital name:<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_5_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_29\" class=\"gfield gfield--type-section gfield--input-type-section gsection just-divider field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_51\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-no-rule field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Payment and Delivery Information<\/h3><\/div><fieldset id=\"field_5_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Select delivery method:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_52'>\n\t\t\t<div class='gchoice gchoice_5_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Pick up books at Branford office at 53 School Ground Road, Branford, CT 06405 for no fee. Pick-ups must be scheduled in advance. A Books for Kids coordinator will contact you when your books are ready for pick-up.'  id='choice_5_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_52_0' id='label_5_52_0' class='gform-field-label gform-field-label--type-inline'>Pick up books at Branford office at 53 School Ground Road, Branford, CT 06405 for no fee. Pick-ups must be scheduled in advance. A Books for Kids coordinator will contact you when your books are ready for pick-up.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Deliver books for prepaid $15 fee. A Books for Kids coordinator will contact you when your books are ready to arrange a delivery.'  id='choice_5_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_52_1' id='label_5_52_1' class='gform-field-label gform-field-label--type-inline'>Deliver books for prepaid $15 fee. A Books for Kids coordinator will contact you when your books are ready to arrange a delivery.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Select method of payment for delivery:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_54'>\n\t\t\t<div class='gchoice gchoice_5_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Check'  id='choice_5_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_0' id='label_5_54_0' class='gform-field-label gform-field-label--type-inline'>Check<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Debit \/ Credit Card'  id='choice_5_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_1' id='label_5_54_1' class='gform-field-label gform-field-label--type-inline'>Debit \/ Credit Card<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_57'>Name appearing on check:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_5_57' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_58'>Name appearing on debit\/credit card:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_5_58' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_53\" class=\"gfield gfield--type-section gfield--input-type-section gsection just-divider field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_59\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p><strong>MAKE SURE TO FILL OUT ALL REQUIRED FIELDS BEFORE HITTING THE \u201cSUBMIT\u201d BUTTON.<\/strong><\/p>\n<p><strong>AFTER SUBMITTING, WAIT FOR ACKNOWLEDGMENT WITH THE \u201cTHANK YOU \u2013 YOUR BOOK REQUEST HAS BEEN SUBMITTED\u201d MESSAGE.  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Gracias por su paciencia.<br \/>\n[\/vc_column_text][vc_column_text el_class=\u00bbintro-copy\u00bb]PLEASE READ THIS ENTIRE MESSAGE:<br \/>\nThis form is for programs serving children and their families in Connecticut such as: center-based child care; education and school; health care; home child-care providers and religious, nonprofit and community organizations. Read to Grow asks that any request is made at least 4\u20136 weeks in advance. 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