Location:	Select your location... Atlanta, GA Chicago, IL Dallas, TX Framingham, MA Kansas City, KS McLean, VA New York, NY Orange County, CA Philadelphia, PA Phoenix, AZ Richmond, VA San Jose, CA Washington, DC
SECTION 1: CONTACT INFORMATION
School Name:
County/School District:
Who is your city council member?
School Address 1:
School Address 2:
City:
State:	... AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
ZIP Code:
School Contact:	(First) (Last)
Contact's Job Title:
Daytime Phone:
Fax:
Cell Phone:
Evening Phone:
E-mail: (just one, please)
Website Address:
Best Way to Contact:	Phone   E-mail   Fax
Summer Contact Information (if different from above)
Address:
City:
State:	... AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
ZIP Code:
Daytime Phone:
Cell Phone:
Evening Phone:
E-mail: (just one, please)

SECTION 2: STUDENT STATISTICS
School Information
Grade Levels Served:
Current Enrollment:
Demographic Information (we will attempt to provide culturally/linguistically-suitable materials)
Ethnicity Percentage American Indian, Eskimo or Aleut % Asian or Pacific Islander % Black % Hispanic Origin (of any race) % White % Other(s) %
Languages Spoken Percentage First Language (please specify) % Second Language (please specify) % Other(s) (please specify) %
Percentage of Students Eligible for Free or Reduced Lunch:
0-25% 26-40% 41-55% 56-70% 71-80% 81-90% 90%+
Percentage of Students Reading Below Grade Level:
0-25% 26-40% 41-55% 56-70% 71-80% 81-90% 90%+
Estimated Percentage of Students with Home Libraries:
0-25%     26-50%     51-75%     76-100%

SECTION 3: LIBRARY STATUS
Library Description
What is the current condition of your school library? (select one) Non-existent (we do not have a library) We have space for a library but there is little or nothing in it We have a library, but it requires renovation Our library is in good shape, but we really need books Other
Approximate Library Dimensions:	ft. X ft.
Does your library have windows?	Yes   No
Is there a full-time librarian/library staff person?	Yes   No
How many library volunteers do you have?
Books
What is the approximate number of books currently in your library?
Approximately how many library books did you purchase last year?
Approximate average age of books in your library? (select one)
0-5 years 6-10 years	11-20 years 21+ years
What were your circulation statistics during the last school year?
Does your library need any of the following? (Check all that apply) Books Shelving Painting Lighting Technology Library furnishings: tables, task chairs, computer tables, mobile book carts, upholstered or non-upholstered reader chairs, stools, magazine racks, rugs Carpet and carpet installation Signage Bulletin Boards with Reading Themes
What are your current library book needs? (Check all applicable categories) Non-Fiction Fiction General General Math Historical Science Folk Tales Social Studies/History Poetry Biographies Fantasy/Fairy Tales Book Types Book Types Picture Picture Chapter Chapter
Technology
Do your students have access to computers in the library?	Yes   No
How many computers do you currently have?
How old are the computers?
1-3 years     4-7 years     More than 7 years
What is their condition?
Like New     Good     Fair     Poor
Is there Internet access in the library?	Yes   No
How often is your library used?
Daily 3-4 times per week 1-2 times per week Less than once per week
What are your three greatest library needs?
How did you hear about our program?
Has your school library received a renovation or a large donation in the past three years?	Yes   No
If so, what type of donations did you receive, and from whom?

SECTION 4: ATTACHMENTS
You MUST complete this section to be eligible for the READesignSM. Please respond to the following questions, providing any relevant data or additional information that you have not previously addressed in this form. Please keep all responses to one page or less.
Tell us why your library should be selected for the READesignSM program: (2000 characters maximum)
Please provide text from your principal stating his/her commitment to the project and to post-READesignSM maintenance.
In order for your application to be complete, we just need a few more items! I have attached at least five (5) high-quality digital photographs of my library: one photo from each angle of the library as well as one additional photo of a unique area of the library or an area of concern.
I have attached a floor plan of our library space. Please feel free to contact Heart of America via phone at 202.347.6278 or via e-mail at readesign@heartofamerica.org if you have any questions. We look forward to receiving your completed application within two weeks or by the specific deadline provided to you by our staff. Once all application items are received, we will be in touch with you to arrange a follow-up conversation. Thank you for your time!
Prepared by:
Date:	8/19/2008 5:46:24 PM
Phone: