Literacy Council Student Application

First Name:

Last Name:

Email:

Phone:

Address:

City:

State:

Zip Code:

Date of Birth:

Gender: Male Female

Marital Status:
Single
Married
Widowed

Ethnic Group:
Caucasian
African-American
Hispanic
Native American
Asian
Other

Education Level:
8th
9th
10th
11th
12th
High School Diploma
Other

What is your goal?
GED
Reading/Math
Computer Use
Driver's License

Best time for tutoring session:

Have you been tested at South Ark? Yes No

Do you have test scores? Yes No

Please indicate a person to contact if there is an emergency on a volunteer site.
Name:

Phone:

Address:

City:

State:

Zip Code: