Literacy Help & Student Registration

Thank you for being interested in help from the Literacy Council of White County, Arkansas! We offer individual tutoring, small group classes, and consultation. If you have any questions about this form, email whitecountyliteracy@gmail.com
First Name*
Last Name*
Date of Birth
Phone Number*
Address*
City*
State*
Zip Code*
Email
example@example.com
Best Way of Contact*

EmailTextPhone CallPostal Mail
Emergency Contact Name
Emergency Contact Number
Gender

MaleFemale
Ethnicity

American Indian/Alaskan NativeAsianNative Hawaiian/Pacific IslanderBlack/African AmericanHispanic/LatinoWhite/CaucasianOther
Highest Education Level

Less than High School Diploma/GEDHigh School Diploma/GEDSome CollegeUndergraduate DegreeGraduate Degree
Employment Status

EmployedUnemployedRetiredDisabledHomemakerCurrent MilitaryVerteran
Do you have a documented learning disability?
What days can you meet for tutoring or class?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What time would work best for classes or tutoring?

Mornings (Until 12)Afternoons (12-5)Evenings (5 or later)
What class are you interested in?*

Reading SupportReading ComprehensionDyslexia SupportJob SkillsFinancial LiteracyFamily LiteracyComputer Literacy
I was referred by: (choose one)

ASU - BeebeAdult Education100 FamiliesPublic LibraryOther
Is there anything else that we need to know?
Should be Empty: