New Student ReturningStudent
New Haven Adult Education
Meriden/Wallingford Adult Education
Other Adult Education
Where? ______ / ESL BL / (For office use only/registration date)
______
Legal First Name M.I.Legal Last Name Home Telephone #:
______(_____) ______
HomeStreet Address Apt. # City Zip Code
______
E-mail Address: ______Cell Phone: (_____) ______
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Emergency Contact: ______Relationship: ______
Home Phone: (_____) ______Cell Phone______
Name of Employer Work Telephone #
______(_____) ______
Employer’sStreet Address City Zip Code
______
Employment Goals: Employed Unemployed - Seeking Unemployed – Not Seeking/Retired
Current Occupation: ______
Birth date: ______/ ______/ ______
Month Day Year / Country Born: ______How long have you lived in the U.S.? ______
Native Language: ______
Can Read & Write in Native Language? Yes No
Gender: Male Female
Social Security # ______-______-______
Last Grade Completed: ______
Do you have (check all that apply):
High School Diploma GED
Some college or university, no degree
College/university or professional degree
Specify: ______
High School Name: ______
Where was the location of the last school you attended?
(Check ONLY one)
In USA Not in USA / Parent/Guardian of: (check all that apply)
Child(ren) 5 years younger
Child(ren) 6 to 10 years
Child(ren) 11 to 18 years
Welfare Status (check all that apply)
General Assistance (SAGA)
TANF/TFA
Free/Reduced Lunch
Housing Assistance
Others: ______
I understand that student information is confidential and will beused only to administer programs. I authorize Literacy Volunteers to release information concerning my application, assessments, and instructional information to program administration, research, evaluation purposes and/ or other educational / training programs.
Applicant Signature Required:______Date: ______
Ethnicity (must select one)
Hispanic or Latino NOT Hispanic or Latino
Racial Ethnic Group (Select only one)Asian
Black - African American
Black – Non African American
Hispanic/Latino
Native Alaskan
American Indian
Native Hawaiian
Pacific Islander
White
Other: ______
______
U.S. Military Service
Active Duty Reserves
National Guard Veteran
No Military Service
/If you live in New Haven, Check off your neighborhood
Amity Annex
Beaver Hills Dixwell
Downtown Dwight
East Rock East Shore
Edgewood Fair Haven
Fair Haven Heights eigh Hill Northeigh
Hill South Long Wharf
Mill River Newhallville
Prospect Hill Quinnipiac MeadowWest River West RockWestville Wooster Square
Miscellaneous Characteristics (check all that apply)Comm. Alt. Corrections Correctional Facility
Homeless Immigrant
Institutionalized Mother Under 17
Needs Child/Dependent Care Needs Transportation
Reasons/Goals for Enrollment – check all that apply:
EMPLOYMENT
Enter EmploymentRetain Employment
COMMUNITY SERVICES
Earn Citizenship
Use Community Services
Vote
EDUCATION
Improve Basic Skills: Reading __ Writing __
Listening __ Speaking___
Enter College or Post-Secondary Training
Progress Toward HS diploma
Earn a HS diploma /
FAMILY
Increase Involvement in Children’s SchoolingParticipate in Parenting Education
Participate in Parent and Child Together (PACT)
Read More to Children
MILITARY
Enter Military
REQUIRED INSTRUCTION
Court OrderRequired for Public Assistance
For program use only: Disability – Visible Disability – Self-Disclosed (for hidden, non-visible disability)
Disability – Visible & Self-Disclosed
AUDIO/ PHOTO/ VIDEO/ MEDIA RELEASE FORM
I grant permission to Literacy Volunteers of Greater New Haven, Meriden/Wallingford and the Valley and its agents or employees to use photographs, video and/or audio taken of me. These images may be used in educational and documentary materials as well as for program promotion, and for any other purposes deemed appropriate by Literacy Volunteers.
I hereby agree to hold harmless Literacy Volunteers and its agents or employees, including any firm publishing or distributing the finished product, from any claim, damages or liability arising from its use.
The foregoing release, having been read to me this ______day of ______, 20__, is understood and accepted without any limitations.
Name (please print)______
Signature______
What days/times are you available? Please place a in the boxes to show when you can come to class:
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday10am-12pm
12pm-2pm
2pm-4pm
4pm-6pm
6pm-8pm
To which of these locations can you go for tutoring? (please circle)
Downtown New Haven
Anywhere in New Haven
Hamden
Meriden
Wallingford
North Haven
West Haven
Ansonia
Derby
Shelton
Seymour
How will you get to the tutoring sessions?
Drive own car ______Take bus ______
Get a ride ______Walk ______
NOTES: ______
Student Agreement
I understand that these are my responsibilities as a student in the Literacy Volunteers program.
I agree to:
- Meet my tutor in a public space, not in a private home.
- Provide my own transportation to and from class.
- Regularly attend classes with my tutor, with a minimum of 4 hours per month.
- Call my tutor or the office in advance if I cannot attend a class.
- Call my tutor or the office in advance if I will be late for class.
- Complete all homework assignments and practice at least 30 minutes a day during the week.
- Participate in all assessment activities (to review progress) at the Literacy Volunteers office.
- Show safe and appropriate behavior with my tutor.
- Never meet while under the influence of alcohol or drugs.
- Participate in at least two Literacy Volunteers events (includes “Festival of Cultures” Volunteer Appreciation Brunch, “Hear My Voice,” Student Workshops, Student Meetings, Family Storytimes, etc.)
If I fail to do any of these things, I understand that I may be terminated from the program.
______
Name of Student – please print
______
Signature of StudentDate
06/20/2016