Watch this video and complete a 5-question survey and receive a free book from the Literacy Coalition of the Permian Basin! Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone number *Email *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhat is the age of the child in years? *01234What is the sex of the child? *MaleFemaleWhat is the race of the child? *WhiteHispanic or LatinoBlack or African AmericanNative American or a Native of AlaskaAsianPacific IslanderMiddle EasternNorth AfricanWhat is the age of the mother? *What is the age of the father? *What is the race of the mother? *WhiteHispanic or LatinoBlack or African AmericanNative American or a Native of AlaskaAsianPacific IslanderMiddle EasternNorth AfricanWhat is the race of the father? *WhiteHispanic or LatinoBlack or African AmericanNative American or a Native of AlaskaAsianPacific IslanderMiddle EasternNorth AfricanWhat is the highest level of education the mother has completed? *Less than high schoolCompleted high school or its equivalent (GED and vocational school)Some universityBachelors degreeSome years of a Masters program without graduatingCompleted a postgraduate or professional degree (MA, MS, PhD, MD, JD)What is the highest level of education the father has completed? *Less than high schoolCompleted high school or its equivalent (GED and vocational school)Some universityBachelors degreeSome years of a Masters program without graduatingCompleted a postgraduate or professional degree (MA, MS, PhD, MD, JD)What is the household income? *$0 - $12,880$12,880 - $20,000$20,000 - $35,000$35,000 - $50,000$50,000 - $65,000$65,000 - $80,000$80,000+Submit
