Contact Information
First & Middle Name
Last Name
Address
City
State
Zip Code
Cell Phone
Email Address
Emergency Contact Name and Emergency Contact Phone
Demographic Information
Race/Ethnic Group
Native Language
Date of Birth
Age
Employment Information
If yes, where do you work?
Learning Goals
(Select all that Apply)
I would like to particpate in:
(Select all that Apply)
Other
Other Information
How did you hear about us?
Learner Agreement
The focus of The Literacy Center (TLC) is to improve adult literacy. TLC is a substance-free environment. Unfortunately, TLC does not offer childcare and is not equipped to accommodate children.
TLC adult learners are expected:
• To maintain consistent attendance when assigned to a specific TLC program/s.
Please abide by the following TLC policies:
• If sick, do not come to TLC.
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. By signing, you acknowledge that for the protection of the learners and volunteers, a parent/guardian must be present (in visible sight at all times) with anyone under the age of 18 for any TLC class.
Print First & Last Name of Parent/Guardian
Date
Please initial and date below if you give The Literacy Center permission to use written comments or take a photo/video of you for promotional material or publication.
Send
