Learner Intake Form
Please fill out this form if you know of, or are, an Elder and/or a Survivor, who is interested in participating in The Literacy Circle program. We offer literacy skills of reading and writing up to grade 8, as well as learning opportunities through field trips.

Our goal is to provide a friendly learning environment that builds the confidence of Learners, which enhances and expands relationships with the world around them by breaking down literacy barriers.

Thank you for your assistance in completing forms for Elder participation in The Literacy Circle.


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What is the name of the person considering literacy class with The Literacy Circle? *
Where does this person reside?  City/town and province or traditional territory. *
Where were they born?
Best email to contact you or the learner directly? *
Best phone number to contact you or the learner directly? *
How old is this learner? *
Does this learner have any reading or math skills? The Literacy Circles offers different levels of learning based on skills and assessments.   Please give approximate grade level if known.
Does this learner have any accessibility issues ? For example: is in a wheelchair or uses a stroller;  requires help with oxygen tanks; is hard of hearing or is losing eye sight.  Please elaborate so that we can assist with accessibility and we can give the best care while in class.
Does this person have any food allergies or sensitivities?
How did you hear about The Literacy Circle?
Do you have any questions or comments before leaving this intake form?
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