2. First & Last Name:
4. Email Address:
6. Library Card #:
8. Mailing Address:
10. City:
11. State:
12. Zip:
14. Home or Cell Phone:
15. Work Phone:
17. Can we contact you at work?

    1. Yes
    2. No
19. Preferred Method of Contact:
    -- Select One --Home PhoneWork PhoneEmail Address
21. Date of Birth:
    Date of Birth:
23. I am:

    1. Male
    2. Female
25. Ethnicity:

    1. Asian
    2. Black
    3. Hispanic/Latino
    4. Native American
    5. Pacific Islander
    6. White
27. Are you a smoker?

    1. Yes
    2. No
28. Is a student who smokes acceptable?

    1. Yes
    2. No
30. Education (highest level completed):
32. Employment Status:

    1. Employed FT
    2. Employed PT
    3. Unemployed
    4. Retired
    5. Disabled
    6. Self-employed
    7. Unknown
34. Employer:
36. Job Title:
38. What is your native language?
40. Please list any other languages spoken:
42. Where did you hear about Project Read?
44. Why does Project Read interest you?
46. Can you tutor twice each week?
    (60-90 minutes each session)
48. Please list the days and times you are available to tutor:
50. Have you had any experience in the teaching or tutoring of adults? Please describe:
52. Please list any special skills, interests, hobbies, or experiences:
54. Please list any community groups that you belong to:
56. Have you volunteered before? If so, where and doing what type of work?
58. In addition to tutoring, would you be willing to donate your skills to Project Read in other ways?

    1. speaking to community groups
    2. distributing Project Read brochures in the community
    3. fundraising
    4. computer work
    5. helping out in the office
    6. child care at Project Read events
60. Please describe any other ways you would like to contribute your skills:
Leave This Blank:


62. Submit

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