This is only a preview. No submissions will be saved, nor will emails be sent.
Date
*
$
$
One Time
Recurring
Student Information
*
$
Student Information
$
One Time
Recurring
Name
*
$
First Name
Last Name
$
One Time
Recurring
Email
*
$
$
One Time
Recurring
Cell Phone
*
$
$
One Time
Recurring
Address
*
$
Address Line 1
Address Line 2
City
State
Zip
$
One Time
Recurring
What is your gender?
*
Male
Female
$
$
One Time
Recurring
What year were you born?
*
$
$
One Time
Recurring
What country are you from?
*
$
$
One Time
Recurring
What is your native language?
*
$
$
One Time
Recurring
How long have you lived in the United States?
*
0 to 11 months
1 to 4 years
5 to 10 years
11+ years
$
$
One Time
Recurring
Are you married?
*
Married
Single
Divorced
Widowed
$
$
One Time
Recurring
Do you have children?
*
Yes
No
$
$
One Time
Recurring
Education
*
$
Education
$
One Time
Recurring
How much education do you have?
*
Less than 12th grade
H.S Diploma
Some College
Undergraduate Degree
Graduate Degree
Not Available
$
$
One Time
Recurring
Race and Ethnicity
*
$
Race and Ethnicity
$
One Time
Recurring
What is your ethnic group?
*
Asian
Black
Hispanic/Latino(a)
Native American
Other
White
$
$
One Time
Recurring
Work Information
*
$
Work Information
$
One Time
Recurring
Do you work?
*
Full-Time
Part-Time
Unemployed
Disabled
Retired
Not in Labor Market
Seeking Work
Not Available
$
$
One Time
Recurring
What is your job?
*
$
$
One Time
Recurring
Where do you work?
*
$
$
One Time
Recurring
English Assessment Test
*
$
English Assessment Test
$
One Time
Recurring
Every student must take a short (20 minutes) English Assessment Test before being matched with an English tutor. The test will take place in the cafeteria of the PeopleCare Center, 120 Finderne Avenue, Bridgewater. First come/first served. You may have to wait.
Register for the English Test
*
Thursday, April 4, from 11:30 am - 1 pm.
I cannot make this date. Please contact me.
$
$
One Time
Recurring
Tutoring Information
*
$
Tutoring Information
$
One Time
Recurring
Student Type
*
Basic Literacy
ESL
$
$
One Time
Recurring
Tutor Preference
*
Female
Male
Either
$
$
One Time
Recurring
How would you like your lessons?
*
In-person/Library
Online/Video Chat
Either
$
$
One Time
Recurring
What days and times can you meet your tutor?
*
$
What days and times can you meet your tutor?
$
One Time
Recurring
Check all days and times that you can meet
*
$
Monday Mornings
Monday Afternoons
Monday Evenings
Tuesday Mornings
Tuesday Afternoons
Tuesday Evenings
Wednesday Mornings
Wednesday Afternoons
Wednesday Evenings
Thursday Mornings
Thursday Afternoons
Thursday Evenings
Friday Mornings
Friday Afternoons
Saturday Mornings
Saturday Afternoons
$
One Time
Recurring
Goals and Interests
*
$
Goals and Interests
$
One Time
Recurring
Why do you want to improve your English?
*
$
To do better at my job.
To get a better job.
To continue my education.
To help my children.
Speak to teachers, doctors...
For help with everyday tasks.
To be more social.
To use a computer.
To become a U.S. Citizen.
Other
$
One Time
Recurring
Additional Information
*
$
Additional Information
$
One Time
Recurring
Do you have an English speaking contact?
*
$
$
One Time
Recurring
Please list Name, Relationship, Phone, Email
How did you hear about LVSC?
*
Employer
Friends/Family
Library
Literacy Hotline
Newspaper
Other
Other Agency
Other Literacy Organization/Agency
Poster
PR Talk
Search Engine
Special Event
TV or Radio
Website
$
$
One Time
Recurring
Additional Comments
*
$
$
One Time
Recurring