Application to Become a Student Student InformationNon (Obligatwa) Premye Dènye Dat nesans (Obligatwa) MM bare JJ bare YYYY Adrès (Obligatwa) Adrès lari Vil Eta / Pwovens / Rejyon Kòd Postal Konte (Obligatwa)ChwaziKap AtlantikBurlingtonGloucesterMercerMiddlesexMonmouthOseyanSussexHudsonTelefòn lakayTelefòn selilè (Obligatwa)Imèl Sèks Gason Fi Lòt Prefer not to say LòtAre you a U.S. Citizen Wi Non SSN or Tax IDEnglish contact nameRelasyonPhoneWhere were you born?How long have you lived in the United States?Lang natif natalIn your Native language Pale Li Ekri In English Pale Li Ekri Marital status Single Married Divorced Widowed Are you a parent? Wi Non Ages of childrenAre you registered to vote? Wi Non Ras/EtnisiteAre you Hispanic/Latino? Wi Non What is your race? Ameriken natif natal Blan Azyatik Nwa/Afriken Ameriken Native Hawaiian or Pacific Islander Enfòmasyon sou travayAre you Employed full time Employed part time Chomaj Retrete Not looking for work Not available to work Non anplwayè aEdikasyonTanpri verifye nivo edikasyon ou 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? Wi Non Are you currently enrolled in any other Adult Learning Program? Wi Non 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?DisponibilitePlease list the libraries/towns/cities in your area where you can meetWhat times are you available to meet? Morning Afternoon Aswè Do you have transportation? Wi Non How will you get to your tutoring session?Can you attend online tutoring? Wi Non How will you attending online tutoring? Computer Smartphone Tablet Chromebook Lòt... LòtStudent 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.
