1. Did anyone from the Born To Read program visit you when you delivered your baby in Beaufort Memorial Hospital or Hilton Head Hospital?   Yes No

2. Did you use any of the materials you received?   Yes No

3. Do you have a library card?    Yes No

4. Would you like us to send you a library application?   Yes No

5. About how many books do you have in your home that you read to your child?

6. How often do you read to your child?

7. How often does your child read/look at books by himself/herself?

8. Does your child:
         Point to pictures or objects in books?    Yes No

         Say the name of pictures or objects in books? Yes No

         Hold books the right way? Yes No

         Turn the pages of books ? Yes No

         Start at the beginnings of books?  Yes No

9. Child’s date of birth:   

10. Adult Education Opportunities 

      Did you or anyone else in your family ask to be referred for GED or Pre GED services?  Yes No

      If YES

      1.  Have you or your family member received your GED?    Yes No
        Or
      2.  Are you currently working on it?   Yes No

Mother’s Name  (optional):

E-mail (optional):   

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