Parent's Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Number of Children Attending*Name of Child 1*Birthdate of Child 1* MM slash DD slash YYYY School Child 1 Attends*Name of Child 2Birthdate of Child 2 MM slash DD slash YYYY School Child 2 AttendsName of Child 3Birthdate of Child 3 MM slash DD slash YYYY School Child 3 AttendsHow did you hear about Mirowitz's Shared Connections?* Facebook Instagram A friend Email Other (explain below) Which event(s) will you be attending?* November 17 (Mirowitz families only) December 22 (open to the community) Explain here:Are you interested in learning more about PJ Library?* Yes! I already receive PJ Library books! No thanks! We will be taking pictures at the event!* Yes! You can post my child on social media (no names but you might see a nametag) No, please do not post my child on social media!
