Fresno County Public Library

Literacy Services Center

2023-2024 Learner 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 *

Phone type *

Phone Number *

Date of Birth * +

Email Address *

I would like tutoring in the following areas: *

Highest level of education: *

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:

Primary Language:

How old were you when
you learned to speak English?

Have you ever taken English-as-a-Second
Language (ESL) Classes?

Yes

No

Have you ever been enrolled in Special Education classes?

Yes

No

Six words to describe your family

Six words to describe yourself

What are your dreams and aspirations for yourself and/or your family?

Do you have children under 18 years old? *

Yes

No

Please list ALL persons living in your home:

	Name	Date of Birth	Gender	First Language
1.	Name	Date of Birth	Gender	First Language
2.	Name	Date of Birth	Gender	First Language
3.	Name	Date of Birth	Gender	First Language
4.	Name	Date of Birth	Gender	First Language
5.	Name	Date of Birth	Gender	First Language
6.	Name	Date of Birth	Gender	First Language
7.	Name	Date of Birth	Gender	First Language
8.	Name	Date of Birth	Gender	First Language
9.	Name	Date of Birth	Gender	First Language
10.	Name	Date of Birth	Gender	First Language
11.	Name	Date of Birth	Gender	First Language

Anything else you want us to know:

Emergency Contact Name: *

Emergency Contact Relationship: *

Phone Number *

Phone type *

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

I understand that I will be participating along with my child(children) in Family Literacy programs.

Thank you for completing the form.

Signature *

clear

Date * +