Student ID #: Birthdate:* MM slash DD slash YYYY Name:* First Last Address:* Street Address Apt. # City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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:* Male Female Marital Status:* Married Single Divorced Widowed Do you have any children?* Yes No Do you have any dependents?* Yes No Please provide children's names and ages.*Please provide dependent's names and ages.*Email Address:* CLP Candidate?* Yes No Ethnic Group:* Native American Asian African-America White Hispanic Country of Origin:* Education:* Pre-High School High School - No Diploma High School - Diploma (US/Non) Undergraduate Degree (2-4 years) Graduate Degree (6+ years) Occupation:* Employment Status:* Full Time Part Time Unemployed / Seeking Unemployed / Not Seeking Retired On Disability Employer:* Source of Referral:* TV / Radio Library School Website Newspaper Poster / Flyer Employer Friend / Family Government Agency NMCL Special Event Annual 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:* Female Male No Preference Location 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 Impaired Wheelchair Physically Disabled Frequent Breaks Diagnosed Learning Disability Emergency Contact Name:* First Last Emergency Contact Phone Number:* Δ
