John Wood Community College Adult Literacy Program
John Wood Community College Adult Literacy Program
Information provided will be kept confidential.
Name
Name
*
First
Last
Date of birth
Date of birth
*
/
MM
/
DD
YYYY
Gender
*
Gender
Male
Female
Other
Other
Address
Address
*
Street Address
Address Line 2
City
Contact Information
Email
*
Phone
Phone
*
-
###
-
###
####
How would you prefer to be contacted?
*
How would you prefer to be contacted?
Email
Phone call
Text message
Do you have transportation?
*
Do you have transportation?
Yes
No
Emergency Contact
Emergency Contact
First
Last
Emergency Contact's Phone
Emergency Contact's Phone
-
###
-
###
####
What is your race/ethnic group?
What is your race/ethnic group?
American Indian/Alaskan Native
White/European American
Hispanic/Latino/Latina/Chicano/Chicana
Asian/Asian American
Arab American/Middle Eastern/North African
Native Hawaiian/Pacific Islander
Unknown
Other not listed
Other not listed
Are you fluent in English?
*
Are you fluent in English?
Yes
No
Please list the other language(s) you are fluent.
*
Education/Employment
School type
School type
US based schooling
Non-US based schooling
Number of school years completed
No schooling
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
HS Diploma or Alternative Credential
GED credential
Some college, no degree
College or Profession Degree
Unknown
Employment status
*
Employment status
Unemployed
Seasonal
Employed part-time
Employed full-time
If you are employed, please list the number of hours you work per week.
*
What is your occupation?
*
Student status
Are there any barriers that would prevent you from participating (i.e. classroom location, seating requirements, dyslexia, hearing, vision, etc.)
Do you have any tutor preferences? (male or female, etc)
When are you available to meet?
When are you available to meet?
Morning
Afternoon
Evening
What are your preferred day(s) to meet?
What are your preferred day(s) to meet?
Monday
Tuesday
Wednesday
Thursday
Friday
What goals do you have in receiving tutoring?
*
What goals do you have in receiving tutoring?
Improve basic reading skills
Improve English language skills
Improve basic math skills
Earn GED / high school equivalent
Pass Accuplacer or WorkKeys exam
Obtain or improve job skills
Pass Illinois driver's exam
Obtain US citizenship
Other
Other
How did you hear about the program?
How did you hear about the program?
Adult Education instructor
Other instructor
Employer
Community organization
News or commercial
Social media (Facebook, etc.)
Flyer or poster
Friend or relative
Case manager
Other
Other