Youth Learner Interest Form
Learner Basic Information (Confidential)
Today's Date *
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Child's Name: *
Your answer
Parent/Legal Guardian Name: *
Your answer
Parent's Phone Number: *
Your answer
Parent's Email: *
Your answer
Address: *
Your answer
Child's Date of Birth: *
MM
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DD
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YYYY
Child's Gender: *
Child's Spoken Languages: *
Your answer
What grade did the child last finish? *
Your answer
Child's Learning Goal: *
Your answer
Child's School: *
Your answer
Name of Child's Teacher: *
Your answer
Check all programs that interest you: *
Required
How did you hear about the South Baldwin Literacy Council? *
Your answer
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