Imperial County Library

Imperial County Library

ALS Intake Form

CLLS Program

• ALS
• ESL
• FLS

Participant

• Learner
• Tutor
• Volunteer

Date *

Library *

Checkboxes

• Release Form
• Library Card

Name *

First

Last

Address *

Address2 *

Phone *

Email *

Birth Place

Gender

Language *

Ethnicity

Birthday *

Education

Employment status *EmployedUnemployedNot in Labor Force

Reading Level1-3rd grade4th-5th grade6th-8th grade9th-12th gradeN/A

How many children do you have? (ages 0-17) *

Source of Referral

• adult learner
• newspaper
• flyer
• volunteer tutor
• radio/TV ads
• family, friends or coworkers
• church or community org.
• library
• online
• other

When are you available? *

• Monday
• Tuesday
• Wednesday
• Thursday
• Friday
• Saturday

Additional Comments

Submit