New Tutor

Key Information

Date:		Staff:
Name:
Address:
City:		State:		Zip:

Home Phone:		OK to call home?:	Yes No
Work Phone:		OK to call work?:	Yes No
Fax:		Email:

Special Instructions:

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Source: (how did you find out about Literacy Volunteers?)

Source Type:

Newspaper TV Radio Relative/Friend Employer Library Other Community Agency Sign/Billboard/Phone Book Place of Worship Handout/Mailed Leaflet Public Relations Talk Other

Specific Name:

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Demographics: (how did you find out about Literacy Volunteers?)

Gender:	Male Female	Birthdate:
Ethnicity:	Asian Black Hispanic Native White Multiple	Marital Status:	Single Married Divorced Widowed

Birthplace:

Spouse's Name:

Optional: Place of Worship (for public relations purposes):

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Employment:

Full-time Part-time Retired Not looking for work

Title:
Employer:
Occupation:

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Education:

Level of Education:

<12 grade High School Diploma Some College Undergraduate Degree Graduate Degree Other

Degree:
Native Language:
Other Languages:

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Volunteer Position Sought:

Choose as many as you are interested in:

Basic Literacy Tutor English for Speakers of Other Languages Tutor Born-to-Read Volunteer Tutor Trainer Special Events Volunteer Clerical Assistant Computer Lab Assistant Board Member

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Why do you want to be a literacy volunteer?:

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Previous volunteer experience?:

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When are you UNAVAILABLE to meet?:

Location Preference:

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Literacy Training (Please indicate if you have been previously trained by listing certifying organization):

Basic Literacy Training:
English for Speakers of Other Languages Training:
Other Training:
Re-certification:
Continuing Ed. Workshops:

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References (Please list name, address, phone #, and relationship of 2 non-family members.):

Occasionally we have paid part-time teaching coordinator positions available for our experienced volunteers. Would you have future interest in such a position?

Yes No