Home
About Us
Our Programs
Contact Us
New Learner Application Form
Tutors
order
login
History
Board of Directors
Calendar
Summer Class Pictures
un-SCRABBLE 2007
Team Un-SCRABBLE 2008
Hmong New Year Book
Unscrabble 07 photos
Map to Literacy Council
New Volunteer Registration Form
Monthly Tutor-Learner Report Form
ESL Resources
Portage County Literacy Council
Learner Application Form
Learner's name:
Street address:
E-mail address:
Home Phone:
Work Phone:
Birth Date:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
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 1
child 2
child 3
child 4
child 5
--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
child 6
child 7
child 8
child 9
child 10
--
1
0
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Race/Ethnicity:
Asian
Black/African American
Caucasian
Hispanic
Native American
Pacific Islander
Other
Annual
household income:
less than $12,000
$12,000 - $14,999
$15,000 - $24,999
$25,000 - $34,999
$35,000 - $49,999
$50,000 - $74,999
$75,000 or more
Number of people living in household:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20 or more
Thank you for any information you can provide.
