Fresno County Library
          
         
         
    
 
 
 
          
         
         
    
 
 
 
          
         
         
    
 
 
 
Fresno County Public Library
Literacy Services Center

2020-2021 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.

 +
 +

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? *
 

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

Have you ever taken English-as-a-Second
Language (ESL) Classes?
Have you ever been enrolled in Special Education classes?

Do you have children under 18 years old?  *
Please list ALL persons living in your home:
 NameDate of BirthGenderFirst Language
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

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
 +
Powered byFormsite