Learner Name: 

Social Security #:

Address:

Home Telephone:

Cell:

Email Address: 

Birth date:

Age:

Gender:

Marital Status:

Do you have children? how many?Age:

Employer:  Employer phone #

Full-time

Part-time

Retired

Seeking work

Not seeking work

Contact Person (only if needed):

Relationship:  Phone:

Ethnicity:

Asian                        Black, non-Hispanic Origin                        Hispanic/Latino

White, non-Hispanic Origin                Other:

What is your native language? 

What country are you from? 

How long have you been in the US?

Educational Information

Student Goals (select all that apply)

Get a job                        

Improve job skills   

Get a drivers license

Obtain GED                  

Obtain citizenship  

Help your children

Learn to vote      

Enter training program   

Learn money skills

Learn health skills         

Get involved locally      

Other

Comments:

Last Grade Completed

0-4

5-8

9-11

HS Diploma

Some college

College Degree

Have you had any training or education since school?

Can you read/write in your native language?

Can you speak any other languages?

English Language Skills

Can you communicate in English?

Have you studied English before?

Are you in any other classes now?

Where? For how long?

Which is most important for you to practice?

Reading

Writing

Speaking

Grammar

All

Time/Days available for tutoring

Monday

Tuesday

Wednesday 

Thursday 

Friday

Saturday

Sunday

Can you drive?

Do you have transportation?

How far can you drive to meet?

If needed, can a tutor come to your house?

Your tutor preference: Female Male No preference

Special Needs:

Hearing Impaired

Wheelchair

Sight

Irregular schedule

Learning disability

Homebound

Public assistance

Homeless

Other

Optional education history

Did you miss much school?

Did you repeat any grades in school?        Which

What were your best subjects?

What were your worst subjects?

What, if any, difficulties did you have in school?

Did you receive testing or special help in school?

Additional Information:

              Name: 

            Email: 

    Comments: