Community Literacy

Thank you very much for your interest in free English tutoring at Erie Neighborhood House! Please fill out this intake form and someone from our team will contact you about next steps.

Community Literacy Intake Form

Information provided will be kept confidential in accordance with the Family Educational Rights and Privacy Act of 1974 (P.L. 93-380)

Basic Information
First Name*
Middle Name
Last Name*
Date of Birth*
MM slash DD slash YYYY
Age
Gender*
Street Address*
City
State
Zip Code*
Neighborhood
Home Phone*
Cell Phone
Email
Additional Information
Are you foreign born?
Are you a refugee?
What year did you enter the US?
What is your country of birth?
Please select one of the following:
What is your cultural heritage?
Please identify your primary racial/ethnic group:*
Military Service
- Yes
- No
What is your primary language?
Do you know a second language?
If yes, please specify:
What is your English speaking level?
Do you have a disability?
- No disability
- Physical disability
- Developmental disability
- Mental disability
- Learning disability
- Multiple disabilities
- Not Disclosed
- Other
What is your highest education level completed?
Education in the United States?
If no, what country?
What is your marital status?
What is your household size?
Number of Adults?
Number of Children?
Employment and Income
Does your family receive Public Assistance? (Please select all that apply)
- None
- SSI (Disability)
- TANF
- WIC
- Child Support
- Food Stamps (LINK card)
- Medical Card
- Other
Are you currently employed?
What is your job title/occupation?
Do you receive unemployment compensation?
Are you the primary provider of your household?
What is your annual income?
What is your household's annual income?
Referral Source
How did you hear about this program?
If from an Erie House program, which program?
If from an external source, what source?
English Proficiency
From 1 to 10, what number do you think describes your knowledge of English?
Have you ever taken English classes or studied English?
Availability
Availability to Study English
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Phone
This field is for validation purposes and should be left unchanged.