Contact Information
First Name
Last Name
Address
City
State
Zip Code
Cell Phone
Home Phone
Email Address
Demographic Information
Race/Ethnic Group
Native Language
Date of Birth
Age
Employment Information
If yes, where do you work?
Total Annual Family Income
Learning Goals
(Select all that Apply)
Civics (Register to vote, prepare for citizenship exam, learn United States' history, participate in community groups, tell your personal story) Life Skills (Get driver’s license, take down messages, talk on the phone, use maps/ask for directions, read menus, read newspapers, understand road signs, understand shopping signs/labels, fill out legal documents, financial literacy, health literacy) Children’s Education (Read to children, help them with homework, talk with teachers, get involved with schools) Computer (Learn basics, use Internet, use e-mail, create documents, web-based learning, typing)
Other
Other Information
How did you hear about us?
Learner Agreement
TLC adult learners are expected:
• To maintain consistent attendance when assigned to a specific TLC program/s.
Please abide by the following TLC policies:
•TLC is not liable for children. Children are never to be left without a parent or guardian.
I acknowledge I have read and I accept the above TLC expectations and policies:
Print First & Last Name
Date
If learner is younger than 18 years of age, parent/guardian signature is required below.
Print First & Last Name of Parent/Guardian
Date
Send
