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Student Intake Form 25/26
Thank you for your interest in English classes with Literacy Volunteers at Family Centers! Please submit your application below! Thank you!
¡Gracias por su interés en clases de inglés con Literacy Volunteers at Family Centers! Por favor, use esta solicitud para registrarse. ¡Gracias!
Дякуємо за вашу зацікавленість у заняттях з англійської мови з Literacy Volunteers at Family Centers! Будь ласка, заповніть заявку нижче! Дякуємо!
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* Indicates required question
First Name (nombre)
*
Your answer
Middle Name (segundo nombre)
Your answer
Last Name (apellido)
*
Your answer
Cell Phone Number (teléfono movil): ###-###-####
*
Your answer
All program information is sent by text message or phone call. Please confirm that we may send text messages or leave a voice mail to the phone number provided. (Toda la información de el programa es envíada por texto o llamada telefonica. Por favor, confirme que acepta recibir mensajes de texto o llamadas telefonicas en este número.)
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Yes
No
Email (Correo electrónico)
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Your answer
Gender: How do you identify? (Género)
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Female (mujer)
Male (hombre)
Non-Binary or Other (No binario u otro)
No Answer/Prefer Not to Disclose (Prefiere no contestar)
Other:
Birth date (mm/dd/yyyy) (Fecha de nacimiento)
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MM
/
DD
/
YYYY
Country of Birth (País de nacimiento)
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Your answer
Address (Apartment/House # and Street) (Dirección - Calle y numero de apartamento)
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Your answer
City and Zip Code (Ciudad y código postal)
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Your answer
Ethnicity (Etnicidad)
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Hispanic or Latino
NOT Hispanic or Latino
Race (Raza)
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White
Black or African American
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Two or More Races
Other:
Marital Status (Estado Civil)
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Single (Soltero/a)
Married (Casado/a)
Partner (Pareja)
Separated (Separado/a)
Divorced (Divorciado/a)
Widowed (Viudo/a)
Highest Education Level (Nivel de educación)
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No schooling
Infant/Toddler
Preschool
Pre-Kindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade (No Diploma)
11th Grade (No Diploma)
12th Grade (No Diploma)
Secondary School (High School) Diploma
Secondary School Equivalent (GED)
Some Post-Secondary (College/University) Education (No Degree)
Post-Secondary (College/University) Degree OR Professional Degree
Graduate Degree (Maestria)
Where did you receive your highest educational/professional degree? (Dónde alcanzó el nivel más alto de educación?)
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In the United States (U.S.)
NOT in the United States (U.S.)
Are you enrolled in College/University, Professional Certification/Training in the U.S.?
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Yes, in the United States (U.S.)
Yes, NOT in the United States (U.S.)
No
If YES, Name of College/University, Professional Certification/Training in the U.S.? if NO write n/a
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Your answer
What is your primary language? (¿Cuál es su idioma principal? )
*
Arabic
Creole
English
Farsi
French
Japanese
Mandarin
Portuguese
Russian
Spanish
Ukrainian
Other:
Do you read and write in your native language? ( ¿Sabe leer y escribir en su idioma nativo?)
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Yes
No
Emergency Contact Name: a person we may contact in the case of an emergency (contacto de emergencia)
*
Your answer
Emergency Contact Phone Number (Número de teléfono de su contacto de emergencia): ###-###-####
*
Your answer
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