Student Application Form

Are you the Student?*

Yes
No

Your Name (If Not Student)

Relationship to Student

Your Phone Number

Are you the English speaking contact for the student?*

Yes
No

Please specify English speaking contact:*

English Speaking Contact phone number:*

STUDENT INFORMATION

Full Name of Student*

Gender*

Male
Female

Preferred Pronouns

She / Her / Hers
He / Him / His
Other

Address*

Street Address City State

Zip Code

Cell Number*

Email Address

Please tell us the best time to contact you:*

PERSONAL INFORMATION

Employment Status*

Job Title

Employer

Are you looking to improve your English skills in order to get a job or a better job?*

Yes
No

Marital Status*

Do you have any children?*

Yes
No

List children ages

Your Date of Birth (mm/dd/yyyy)*

Birthplace*

Language spoken at home:*

Ethnic Group (check all that apply)

Other Ethnic Group*

Housing

Household Income

BACKGROUND

Education Level You Have Completed

Last Grade Completed:

Field of Study:

US Based Schooling?

Yes
No

Learning Disability?

Yes
No

Learning Disability (please specify)*

If Other please specify*

Goal

AVAILABILITY

Please indicate all times that you are available for tutoring

Monday

Morning
Early Afternoon
Late Afternoon
Evening

Tuesday

Morning
Early Afternoon
Late Afternoon
Evening

Wednesday

Morning
Early Afternoon
Late Afternoon
Evening

Thursday

Morning
Early Afternoon
Late Afternoon
Evening

Friday

Morning
Early Afternoon
Late Afternoon
Evening

Saturday

Morning
Early Afternoon
Late Afternoon
Evening

Sunday

Morning
Early Afternoon
Late Afternoon
Evening

Tutor Preference

Male
Female
No Preference

Class Preference (Check all that apply)

What technology do you have available for remote tutoring? (check all that apply)

Do you have reliable access to WiFi?*

Yes
No

What tutoring platforms are you comfortable using? (check all that apply)*

For face-to-face tutoring, please list the libraries/towns/cities in your area where you can meet?

How will you get to class? (check all that apply)

Why do you want to join the program? (Check all that apply)*

For my job/to find a job
To get my high school diploma
To help my child/children with school
To read and fill out important forms, labels, schedules, etc.
To use a computer/the internet
To become a U.S. Citizen
Other goals and interests

Other goals and interests

How did you hear about us?*

In order to get started, we will need to speak with you and assess your level (in person assessments are not available at this time).*

I prefer a phone call
I prefer a video chat

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Student Application Form

STUDENT INFORMATION

PERSONAL INFORMATION

BACKGROUND

AVAILABILITY

Map

Contact