Application to Become a Student Student Information姓名（必填） 第一 最后 出生日期（必填） MM/DD/YYYY 地址（必填） 街道地址 城市 州/省/地区 邮政编码 县（必填）选择大西洋角伯灵顿格洛斯特美世米德尔塞克斯蒙茅斯海洋萨塞克斯Hudson座机手机（必填）电子邮件 性 男性 女性 其他 Prefer not to say 其他Are you a U.S. Citizen 是的 不 SSN or Tax IDEnglish contact name关系PhoneWhere were you born?How long have you lived in the United States?母语In your Native language 说话 阅读 写 In English 说话 阅读 写 Marital status Single Married Divorced Widowed Are you a parent? 是的 不 Ages of childrenAre you registered to vote? 是的 不 种族/族裔Are you Hispanic/Latino? 是的 不 What is your race? 美洲原住民 白色 亚洲 黑人/非裔美国人 Native Hawaiian or Pacific Islander 工作信息Are you Employed full time Employed part time 失业 已退休 Not looking for work Not available to work 雇主名称教育请选择您的受教育程度 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? 是的 不 Are you currently enrolled in any other Adult Learning Program? 是的 不 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?供应情况Please list the libraries/towns/cities in your area where you can meetWhat times are you available to meet? Morning Afternoon 晚上 Do you have transportation? 是的 不 How will you get to your tutoring session?Can you attend online tutoring? 是的 不 How will you attending online tutoring? Computer Smartphone Tablet Chromebook 其他... 其他Student 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.
