Student ID #:*Birthdate:* Date Format: MM slash DD slash YYYY Name:* First Last Address:* Street Address Apt. # City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (home):*Phone (cell):*Assessment #:*CONFIDENTIAL STATISTICAL INFORMATIONAll information during this interview is strictly confidential. Your Tutor receives your name, phone number, education, educational goals, email, test scores, a copy of the student contract and time and place you’re available to meet.Identified Gender:*MaleFemaleMarital Status:*MarriedSingleDivorcedWidowedDo you have any children?*YesNoDo you have any dependents?*YesNoPlease provide children's names and ages.*Please provide dependent's names and ages.*Email Address:* CLP Candidate?*YesNoEthnic Group:*Native AmericanAsianAfrican-AmericaWhiteHispanicCountry of Origin:*Education:*Pre-High SchoolHigh School - No DiplomaHigh School - Diploma (US/Non)Undergraduate Degree (2-4 years)Graduate Degree (6+ years)Occupation:*Employment Status:*Full TimePart TimeUnemployed / SeekingUnemployed / Not SeekingRetiredOn DisabilityEmployer:*Source of Referral:*TV / RadioLibrarySchoolWebsiteNewspaperPoster / FlyerEmployerFriend / FamilyGovernment AgencyNMCLSpecial EventAnnual Family Income:*$0-11,999$12,000-14,999$15,000-19,999$20,000-29,999$30,000-39,999$40,000-49,999$50,000-59,999$60,000+Public Assistance:* SNAP (Food Stamps) TANF (Welfare) Medicaid G.A. (Pueblos) Tutor Preference:*FemaleMaleNo PreferenceLocation Preference:*Best Time to Meet With a Tutor:*Please provide options Monday through Sunday AM and PM.How will you get to tutoring?*I will drive myself.Someone will drive me.Do you have any special needs?*Hearing ImpairedWheelchairPhysically DisabledFrequent BreaksDiagnosed Learning DisabilityEmergency Contact Name:* First Last Emergency Contact Phone Number:*
