Referral Form

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 community memberships and events, and regular literacy-tips via text messages, along with a $500 children's savings account to put toward college or career. 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 bb@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 Durham 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

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 Book Harvest and do they give consent for someone from the 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