Adult Literacy Learner Intake Form
Step 1 of 2: Submit
Name
*
Date of Birth
*
Address
*
Phone Number
*
Email Address
*
Gender
*
Male
Female
Transgender
Gender Non-ConformingNon-Binary/Gender Queer
Unknown
Decline To State
Racial / Ethnic Group
*
African/Black/African American
American Indian / Alaska Native
Arab American / Middle Eastern / North African
Asian / Asian American
Hispanic/Latinx/Chicano or Chicana
Native Hawaiian / Pacific Islander
White / European American
Race / Ethnicity Not Listed
More than One Race / Ethnicity
Unknown / Decline to State
Seeking Assistance in the Following Subject(s)
*
Basic Reading
Basic Math
ESL
Basic Computer Technology
Employment Status
*
Part-time
Full-time
Retired unemployed / Seeking to Work
Unemployed / Not Seeking to Work
Do you have a library card?
*
Yes
No
Would you like assistance applying for a library card?
*
Yes
No
*
indicates required fields