Fresno County Public Library

Literacy Services Center

2023-2024 Literacy Volunteer Intake Form

Your identifying information will not be shared. We gather information for funding purposes. The only information reported is your gender, age, race and ethnicity.

Today's Date: * +

How did you find out about this program? *

First Name *

Middle Initial *

Last Name *

Mailing Address *

City *

State *

Zip Code *

Date of Birth * +

Phone type *

Phone Number *

Phone type

Phone Number

Email Address *

What gender do you identify as? *

Ethnicity Identity and origin:
Are you of Hispanic, Latinx or Spanish origin? *

No, not of Hispanic, Latinx, or Spanish origin

Yes, Mexican, Mexican American, Chicanx

Yes, Puerto Rican

Yes, Cuban

Yes, another Hispanic, Latinx or Spanish origin. If you like, you can write in your origin below: for example, Salvadorian, Dominican, Columbian, Guatemalan, Ecuadorian, etc. Yes, another Hispanic, Latinx or Spanish origin. If you like, you can write in your origin below: for example, Salvadorian, Dominican, Columbian, Guatemalan, Ecuadorian, etc.

What is your race? (Please select as many responses as you like) *

Native American or Alaskan Native - If you like, you can write your enrolled or principal tribe(s) below: for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community etc. Native American or Alaskan Native - If you like, you can write your enrolled or principal tribe(s) below: for example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community etc.

Black or African American - If you like, you can write in your origin below: for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. Black or African American - If you like, you can write in your origin below: for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

Chinese

Vietnamese

Korean

Asian Indian

Filipino

Japanese

Samoan

Chamorro

Native Hawaiian

White - If you like, you can write in your origin below: for example, German, Irish, English, Italian, Lebanese, Egyptian, etc. White - If you like, you can write in your origin below: for example, German, Irish, English, Italian, Lebanese, Egyptian, etc.

Other Pacific Islander - If you like, you can write in your origin below: for example, Tongan, Fijian, Marshallese, etc. Other Pacific Islander - If you like, you can write in your origin below: for example, Tongan, Fijian, Marshallese, etc.

Some other race - If you like, you can write in your origin below: Some other race - If you like, you can write in your origin below:

Emergency Contact Name: *

Emergency Contact Relationship: *

Phone Number *

Phone type *

Available to volunteer (please write the times of availability)

	Times available
Monday	Times available
Tuesday	Times available
Wednesday	Times available
Thursday	Times available
Friday	Times available
Saturday	Times available
Sunday	Times available

Check all that apply

1. Have a special interest in or experience with these subjects: *

2. I am interested in working with these library literacy projects: *

3. Would be willing to tutor a learner with these special challenges:

4. Do you speak any languages other than English? *

5. Skills *

6. Do you have a preference or a specific area of interest that you would like to be able to tutor in if so what? *

7. I have the technology to tutor remotely: *

Phone

Computer

Tablet/ I PAD

Reliable WIFI

8. Have experience with the following technological platforms and/or applications: *

9. Please Share a little about yourself. Do you have any particular hobbies or special interests you would be willing to share with our learners? *

10. Six words to describe yourself

	-	-
-	-	-
-	-	-
-	-	-

11. Are you a member of a community organization with possible interests in partnering with the library?

Organization:

Contact (if different from you)

Telephone:

Email Address

Zoom calls may be recorded for record-keeping, quality assurance, and training purposes.

Thank you for completing the form. I certify that all the information provided is accurate.

Signature *

clear

Date * +