CL Get Started- English - Erie Neighborhood House

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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

Comments
This field is for validation purposes and should be left unchanged.

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PROGRAM NEWS & EVENTS

News

May 12 2020

Education Continues at Erie House as ESL and Community Literacy Hold Online Classes and Tutoring

In our English as a Second Language (ESL), Adult Basic Education (ABE), and Community Literacy classes, students gain ...

Jun 17 2019

Erie House Receives $10,000 Grant from the Dollar General Literacy Foundation to Support Adult Literacy

This week, the Dollar General Literacy Foundation awarded Erie Neighborhood House a $10,000 grant to support adult literacy. ...

VIEW ALL NEWS

Events

There are no upcoming program events at this time.

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