Family Resource Center

First Name*

Last Name*

Middle Initial*

Date of Birth*

Gender*

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Phone Number*

Email*

Emergency Contact's Name*

Emergency Contact's Phone*

Relationship to Student*

Have you ever been convicted of a crime?*

YesNo

*Answering YES will not necessarily disqualify you from our program. If you answered YES, please list the date(s) of the conviction(s), the city and state, and the offense(s).

I understand that a criminal background check will be performed by the Literacy Council of Sheboygan County before I am accepted as a volunteer. I authorize any institution, information agency, or law enforcement agency to furnish any and all related information.

Signature*

Any information received as a result of a background check is kept strictly confidential.

Native Language*

Country of Origin*

Other Languages

Ethnic Group*

Education*

Source of Referral*

Employment*

Industry*

Occupation

Employer

Annual Family Income Range*

Marital Status*

Number in Household*

Number of Adults*

Number of Dependents under 18*

Children K-6*

Children Pre-K*

Do you need financial assistance to help pay for your materials?*

YesNo

Tutors and students meet at their local public library or another public location.

Transportation*

YesNo

Tutor Preference*

I am willing to travel to:*

Elkhart Lake
Sheboygan
Kiel
Sheboygan Falls
Plymouth
Random Lake
Oostburg

When will you be available? Check all that apply

Become a Student

New Student Intake Form

Address

Contact Info

Emergency Contact

Language

Other Information

Household Information