Read Muskegon Adult Learner Registration

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete the registration form below:

Date *

YYYY

First and Last Name *

Phone Number *

Date of Birth:

YYYY

Place of Birth (City/State/Country):

Gender:

Female

Male

Prefer not to say

Other:

Clear selection

Address: *

Marital Status: *

Single

Married

Divorced

Widow(er)

Required

What program(s) are your interested in? *

English Language Class

English Language 1:1 Tutoring or Small Groups

1:1 Reading Tutoring

Required

Email Address *

Ethnicity/Race (Select all that Apply):

American Indian/Alaska Native

Asian

White

Hispanic/Latino

Black/African American

Native Hawiian/Pacific Islander

Other:

What level of education did you complete? *

Did you go to school in the United States? *

Yes

Required

Do you have a learning disability? *

Yes

Required

If yes, what is your diagnosis?

Do you have a job? *

Yes

Required

If yes, please select:

Full-Time

Part-Time

Clear selection

Do you receive government benefits? *

Yes

Required

Do you have trouble finding child care? *

Yes

Are you in foster care or were you in foster care?
*

Yes

Do you need help with technology? (ex: using a computer or phone)
*

Yes

Do you have a physical or mental disability?
*

Yes

Do you need help speaking English?
*

Yes

Are you homeless?
*

Yes

Are you a migrant or seasonal worker on a farm?
*

Yes

Are you a single parent?
*

Yes

Do you have a history with drug or alcohol abuse?
*

Yes

Do you have transportation to get to work?
*

Yes

Are you a veteran?
*

Yes

Goals: (Check all that apply)

I would like to get my High School diploma or GED

I want to improve my English

I would like to enroll in college

I want to learn more skills to get better job

I would like to get a job

I want to get involved in my community

I want to get involved with my children’s education

I want to help my children read and write

I want off public support (benefits like food stamps)

Other:

Emergency Contact: (Name, Phone, Relationship)

Availability for Tutoring : (Days & Times)

I grant Read Muskegon, its representatives and employees the right to take photographs of me and my property. I authorize Read Muskegon, its assigns and transferee to copyrights, use and publish the same in print and/or electronically.

I agree that Read Muskegon may use such photographs of me for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.

I have read and understand the above statement, by checking this box and typing my name below, I agree that I am electronically signing this consent.

I decline consent

I grant permission for Read Muskegon to conduct a criminal background check. I certify that the above information is complete, true and accurate.
*

YYYY

Check Box:
*

By checking this box and typing my name below, I agree that I am electronically signing this application.

Required

Signature:
*

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Read Muskegon.

Does this form look suspicious? Report

Forms