Literacy Learners Admission

About You

Legal First Name

Middle Initial

Legal Last Name

Preferred/Chosen First Name

Birthdate

MM/DD/YYYY

Gender

FemaleMaleNon-Binary

Do you have a Social Security Number?

YesNo

Preferred Location

Social Security Number

Contact Information

Street Address

City

State

Zipcode

Phone Number

Phone Number Type

Email Address

Email Confirmation

Email Match Check

Email Match Error

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relation

Other Information

Do you have a High School Diploma or Equivalent? YesNo	What was the last grade level completed?
Which high school did you attend? Search for your school, state you attended, or GED.	What year did you graduate?
Disability Status	Do you have a Library Card YesNo
Ethnic Origin	Is English your first language? YesNo
Work Status	How long have you been in the United States?
How many years of English lessons have you had?	Current Occupation
Hours worked per week Enter a whole number only (ex: 20, not 20-30)

Literacy Goals

What is your goal? (GED is not a goal)

Tell us your goal

Are you enrolled in a GED or ESL class right now?

YesNo

HSID