"*" indicates required fields Program* Adults Building Literacy English Language Learners Distance Learning HSE 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 Identified Gender:* Male Female Other Marital Status*Choose from dropdown:MarriedNot MarriedBirthdate:* MM slash DD slash YYYY Languages Spoken*Untitled* Speak Read Write Email* Phone (home):*Okay to Call?* Yes No Phone (cell):*Okay to Call?* Yes No Phone (work):*Okay to Call?* Yes No CONFIDENTIAL STATISTICAL INFORMATIONEthnic Group:* Native American Asian African-America White Hispanic Other Education:* Pre-High School High School - No Diploma High School - Diploma (US/Non) Undergraduate Degree (2-4 years) Graduate Degree (6+ years) Other Employment Status:* Full Time Part Time Unemployed / Seeking Unemployed / Not Seeking Retired On Disability Other Occupation:*Employer:*Source of Referral:* TV / Radio Library School Website Newspaper Poster / Flyer Employer Friend / Family Government Agency NMCL Special Event Other Instruction Preference*Choose from dropdown:One-to-OneSmall GroupEitherLearner Preference*Choose from dropdown:MaleFemaleEitherBest Time to Meet With a Student:*Please provide options Monday through Sunday AM and PM.How will you get to tutoring?* I will drive myself. Someone will drive me. Other Do you have any special needs?* Hearing Impaired Wheelchair Physically Disabled Frequent Breaks Diagnosed Learning Disability Other Emergency Contact Name:* First Last Emergency Contact Phone Number:*CONFIDENTIALITY STATEMENTAt ReadWest Adult Literacy Center, we are committed to maintaining the confidentiality of both our learners and volunteers. We protect all personal information shared with us—including names, contact details, and other sensitive data—and ensure it is used only for purposes directly related to our programs. Volunteer and learner information will never be shared with outside parties without consent, except as required by law. All records are securely stored, and access is limited to authorized personnel. We value your trust and are dedicated to providing a safe, respectful, and confidential environment for everyone involved. Δ
