Application to Become a Student Student InformationName(Required) First Last Date of birth(Required) MM slash DD slash YYYY Address(Required) Street Address City State / Province / Region ZIP / Postal Code County(Required)SelectAtlantic CapeBurlingtonGloucesterMercerMiddlesexMonmouthOceanSussexHudsonHome phoneCell phone(Required)Email Sex Male Female Other Prefer not to say OtherAre you a U.S. Citizen Yes No SSN or Tax IDEnglish contact nameRelationshipPhoneWhere were you born?How long have you lived in the United States?Native languageIn your Native language Speak Read Write In English Speak Read Write Marital status Single Married Divorced Widowed Are you a parent? Yes No Ages of childrenAre you registered to vote? Yes No Race/EthnicityAre you Hispanic/Latino? Yes No What is your race? Native American White Asian Black/African American Native Hawaiian or Pacific Islander Work InformationAre you Employed full time Employed part time Unemployed Retired Not looking for work Not available to work Name of employerEducationPlease check your level of education No schooling Did not graduate high school High school diploma or alternate credential GED/TASC/HiSET Some college- no degree College or Professional Degree How many years did you go to high school?U.S. schooling? Yes No Are you currently enrolled in any other Adult Learning Program? Yes No What is the name of the program?Household IncomeWhat is your household income? (the total gross income before taxes, received within a 12-month period by all members of a household above a specified age) $0 to 2,999 $3,000 to 5,999 $6,000 to 8,999 $9,000 to 11,999 $12,000 to 14,999 $15,000 to 19,999 $20,000 to 29,999 $30,000 to 39,999 $40,000 to 49,999 $50,000 or more If over $50,000, what is your household income? $50,000 to 59,999 $60,000 to 69,999 $70,000 to 79,999 $80,000 to 89,999 $90,000 to 99,999 $100,000 or more How many people in your household?AvailabilityPlease list the libraries/towns/cities in your area where you can meetWhat times are you available to meet? Morning Afternoon Evening Do you have transportation? Yes No How will you get to your tutoring session?Can you attend online tutoring? Yes No How will you attending online tutoring? Computer Smartphone Tablet Chromebook Other... OtherStudent Goals & InterestsWhy do you want to join the program? For my job/to find a job To get my high school diploma To help my child/children with school To read and fill out important forms, labels, schedules, etc. To use a computer/the internet To become a US citizen Other goals and interestsHow did you hear about Literacy NJ?CommentsConsent By submitting this form, I certify that the information provided is accurate to the best of my knowledge.
