Manatee Literacy Council · Learner Interest and Registration

Contact Information

Name

*

Prefix

First Name

Last Name

Suffix

Name you prefer to be called / Nickname

Email (primary/main)

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Email (secondary)

Phone (primary/main)

*

Phone (secondary)

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Name of County where you live.

*

Gender

*

Preferred pronouns

*

Date of Birth (the date you were born)

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Enter the month, day and year you were born

How old are you?

Ethnic Group

*

Country of Origin (Country where you were born)

*

Native Language (Mother Tongue)

How many children do you have?

Childs current grade

Please select the current grade of each child.

Pre-school/Pre-K/ VPK

Elementary (K - 5)

Middle school (6 - 8)

High School (9 - 12)

Employment

Employment Status

*

Profession or Job Title

Name of Employer

Have you been convicted of a felony?

*

Yes

No

Felony Info

*

Please enter reason for conviction

Education

Highest Level of Education Completed

Can you read English?

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Yes

No

Please describe on scale of 1 - 10 how well you READ English

(1-reads well, 5-average reader, 10-reads few words)

Can you write English?

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Yes

No

Please describe on scale of 1 - 10 how well you WRITE English

(1-writes well, 10-very limited writing)

Are you comfortable using Zoom or other presentation software/applications?

Yes

No

Do you have any physical disabilities (ex: problems seeing, hearing, etc.)?

*

Yes

No

Please list or explain physical disabilities

*

Please be specific

Do you have any learning disabilities?

*

Yes

No

Please list or explain any learning disabilities.

*

Please be specific

Availability and Location Information

Preferred day for training or tutoring

*

We offer free conversation classes for adult residents of Manatee throughout the week on Zoom. ($10/month for non-residents)

CONVERSATION CLASS

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$0 - I am a Manatee resident and would like to join the Conversation class.

$10 - I am NOT a Manatee resident but would like to join the Conversation class at $10 per month.

$0 - I am not interested in joining the Conversation classes.

$0 - I need more information before joining - please email me.

Please select the equipment you have access to.

Computer/Laptop

Smart phone (Andriod, iphone,)

Government Issued phone

Tablet/ipad

Internet

Transportation

*

I have No access to transportation

I live near and use public transportation

I have my own transportation (car)

Best Library location for me

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Can you afford to buy your own books?

*

Yes, I can afford to buy my books.

No

Have you worked with Manatee Literacy previously?

Yes, I have worked with Manatee Literacy in the past.

Have you been vaccinated for COVID-19?

*

Please note: MLC is collecting this information for the sole purpose of matching learners and tutors.

Yes

No

Prefer not to answer

How did you hear about our program?

To save mailing costs, we communicate electronically. May we use your email for communication?

*

Note: We NEVER sell or share your email or address.

Yes

No

Photo Release

I understand that my photographs and/or statements will be used in Manatee Literacy Council materials, which may be social media posts, website testimonials, newspaper articles, brochures, educational leaflets, funding requests to donors, annual reports, videos, and other related publications. I understand that this permission is valid indefinitely unless I notify the Manatee Literacy Council otherwise.

Do you agree with the above photo release?

*

Yes, I give my full permission to Manatee Literacy Council to utilize my photographs and/or statements.

No, I do NOT give permission to utilize my photographs and/or statements.

Please type your name or initials for photo release agreement.

*

Registration Fee

*

$20 - One-time fee

If you are a Manatee county resident and unable to pay the $20 registration fee, please contact our office (941-746-8197)

Payment Info

* You will NOT need a paypal account to pay by credit card. Press the yellow Paypal button on the next page and you will then be allowed to enter a credit card number to complete your application. Paypal is our payment processor and can process credit cards.