Learner Application

Riverside County Library System Literacy Services - Learner Background Information

To be considered eligible for literacy learner, please fill out this form in its entirety.

Date Enter Today's Date

Site Enter the Site Location you would like to attend

First Name

Last Name

Address

City

State

Zip

E-mail Address

Home Phone Number:

Work Phone Number:

Gender Please Choose

Date of Birth MM/DD/YY

Age Group Please Choose

Select the Highest Grade in School Completed Please Choose

Earned outside the United States? Please Choose

Highest Diploma or Degree Earned Please Choose

Personal Status (Mark all that apply)

TANF

WIA IB

Disabled

Dislocated Worker

Displaced Homemaker

Rehabilitation

Single Parent

Veteran

Other

Personal Goals (1) Mark your first choice here

Personal Goals (2) Mark your second choice here

Employment: Are you currently working? Please Choose

If employed, where do you work and what kind of work do you do?

Are you Please Choose

Can you speak, read or write in other languages? Please Choose

Please list what languages (starting with your Native Language) Please list a language and if you can speak, read or write

How did you hear about our program? Please Choose