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Mercer Student Application
1
Start
2
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Student Information
First Name
Last Name
Date of birth
Street Address
City
State
Zip code
Home phone
Cell phone
Email
Gender
Male
Female
Are you a U.S. Citizen?
Yes
No
SSN or Tax ID
English contact name
Relationship
Phone
Where were you born?
How long have you lived in the United States?
Native language
In my native language:
Speak
Read
Write
In English:
Speak
Read
Write
Marital status
Single
Married
Divorced
Widowed
Are you a parent?
Yes
No
Ages of children
Are you registered to vote?
Yes
No
Race/Ethnicity
Are you Hispanic/Latino?
Yes
No
What is your race?
Native American
White
Asian
Black or African-American
Native Hawaiian or Pacific Islander
Work Information
Are you
Employed full time
Employed part time
Unemployed
Retired
Not looking for work
Not available to work
Education
Please 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 Income
What is your household income?
$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?
Availability
Please list the libraries/towns/cities in your area where you can meet
What 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...
How will you attending online tutoring? Other...
Student Goals & Interests
Why 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 U.S. Citizen
Other goals and interests
How did you hear about Literacy NJ?
Comments
By submitting this form, I certify that the information provided is accurate to the best of my knowledge.
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