Forsyth County Referral Form

Referral Page

Book Babies helps families create a home literacy environment from the moment their children are born. Over five years, families who are enrolled in Book Babies receive quarterly home visits from trained literacy coaches, 20 brand-new free books every year, learning opportunities through group events, and regular literacy-tips via text messages. Plus, families receive individualized support for the transition to pre-k and kindergarten to ensure success in school. If you have any trouble with this form, please email us at bbforsyth@bookharvest.org or call/text us at 919-907-0998. Thank you!

Enrollment Criteria

Baby is Medicaid eligible

* Required

Baby is 16 weeks or younger?

* Required

Family lives in Forsyth County

* Required

Caregiver Information

Caregiver First Name

* Required

Caregiver Last Name

* Required

Caregiver DOB * Required

Relationship to Child?

* Required

Caregiver Race or Ethnicity

* Required

Caregiver Cell Phone Number

* Required

Caregiver Home Phone Number

* Required

Caregiver Address 1

* Required

Caregiver Address 2

Caregiver City

* Required

Caregiver State

* Required

Caregiver Zip

* Required

County

Primary language spoken at home

* Required

Family referred by:

* Required

If healthcare provider, community partner, or other please specify.

Referral Source Name

* Required

Referral Source Email and/or Phone

* Required

What is the best way to contact family?

Is this a pregnant person?

Pregnancy Due Date

Additional comments or questions?

Please leave this checkbox blank