Portage County Literacy Council

Learner Application Form
 

Learner's name:


Street address:


E-mail address:


Home Phone:

   Work Phone:


Birth Date:

Sex: male     female

Native Language:


Referred By:


Highest completed grade in...
USA:    Homeland/other country:

Comments:


The following information is not required...However, any peices of this requested information will assist the Portage County Literacy Council in obtaining future funding through state agencies. Information entered in this area will not be associated with the learner's name. We respect privacy.
Ages of children living in household:
(For each child living in the household, please select the age. If more than 10 children live in the household, please submit the ages of the 10 youngest. Select "0" for infants less than 1 year old.)

child 1child 2child 3child 4child 5
 
child 6child 7child 8child 9child 10


Race/Ethnicity:


Annual household income:


Number of people living in household:


Thank you for any information you can provide.