Book Check-Out Form

* Indicates required field

Name *

First

Last

Book Title *

Date *

Questions and/or Comments *

Address Sharing Permission *

Yes No

Submit

Address Sharing Permission

By requesting a book using the Book Check-Out Form, you are giving Ellen Jackson, Chairperson of the Nicole Daune Jackson Foundation, permission to release the participant's address to another member of the Foundation in order to facilitate delivery of the book in a timely manner.

At no other time will a participant's information be released without a parent or guardian's express written consent.