Forsyth County Referral Form

Thank you for your interest in Book Babies, a program that provides home visits, book delivery and literacy coaching from birth through age 5. If you have any trouble with this form, please email us at bookbabies@imprintscares.org or call us at 336-722-6296 ext. 1203. 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

Password

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

Does caregiver give verbal consent to share their contact information with Wake County and do they give consent for someone from the Wake County Book Babies Program to contact them to enroll their family?

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