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Learner Enrollment Form
Learner's Last Name
*
Learner's First Name
*
Parent/Guardian Name
Relationship to the learner
Self
Mother
Father
Guardian
Step parent
Foster Parent
Grandmother
Grandfather
Sibling
Aunt
Uncle
Other
Learner/Parent/Guardian Email Address
Learner/Parent/Guardian Cell Phone
*
Home Phone
Learner/Parent/Guardian Work Phone
Street Address
*
City
*
County
*
Zip Code
*
Date of Birth
*
Gender
*
Male
Female
Gender Queer/Non-Binary
Other
Race/Ethnicity
*
Asian/Hawaiian/Pacific Islander
Black/African American
Hispanic/Latino(a)
Native American/Alaskan
White/Caucasian
Multiracial
Other
Other
Native Language
*
Other languages spoken in the home
In case of emergency, name of person other than the learner
*
Emergency Contact Phone
*
Other than learner’s or parent’s/guardian’s phone
Relationship to the learner
Spouse
Mother
Father
Guardian
Stepmother
Stepfather
Foster Parent
Grandmother
Grandfather
Son
Daugher
Brother
Sister
Aunt
Uncle
Other
Child learner information (adult learners skip to the next section)
Education Information
Child's Current Grade
Name of Child's School
Name of Child's Teacher
Teacher's Email
Can we contact your child’s teacher?
Yes
No
Note: for educational purposes only
Current reading level, grade level, lexile, DRA, Guided Reading…
Does your child have an IEP for Special Education Services?
Yes
No
Does your child have a disability?
Yes
No
What is the disability?
What areas do they receive special ed services?
Adult learner information
Adult learner, do you have a job?
Do you have a drivers license?
What are your goals with this program?
Checkbox
Get a better job, improve job skills
Enter higher education or training
Receive HISET or other similar diplomas
Improve score on standardized test
Advance reading level
Do you have a disabilty?
Yes
No
What is your reading level?
Where and when can you meet with a tutor?
Availability – The more availability you have for times and locations makes it easier to find you a tutor. We make every effort to match you with someone with similar preferences.
What locations can you meet with a tutor?
*
Tutors/Learners must meet in public locations such as libraries, businesses, churches, or online etc.
What day(s) of the week can you meet with a tutor?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Check all that apply
Can you meet with a tutor in the morning, afternoon, evening or any time?
Are you flexible in the days and/or times you can meet?
Yes
No
Would you/the learner be interested in meeting with a tutor online?
Yes
No
Does the learner have a library card?
Yes
No
Additional Information – For statistical purposes only
How did you learn about Ozarks Literacy Council?
Poster/Flyer
Facebook
Ozarks Literacy Council’s WebSite
Internet Search
TV/Radio
Friend/Family
School
Other
Other
Number of people in household
*
Yearly household income
*
$0- $12,000
$12,001-$16,000
$16,001-$20,000
$20,001-$27,750
$27,751-$34,000
34,001 and up
What does the learner read now?
*
What are the favorite types of books?
What interests and hobbies does the learner have?
*
By clicking the submit button below, I give permission for Ozarks Literacy Council to share this information with the tutor and to use for statistical and grant/financial applications. I understand that my name and address will not be used or released to other people, businesses, or agencies without my written permission. Photos may be posted on our social media accounts.
*
Submit Registration Form
