Prospective Learner Questionnaire
Name:
Phone Number:
Email Address:
Address:
What city do you currently live in?
Are you at least 18 years old?
Yes
No
What country are you from?
When did you move to Orange County?
How long do you plan to live in the US?
1-2 Years
3-5 Years
6-10 Years
10+ Years
Do you plan to travel during the year?
Yes
No
Have you participated in other reading, literacy and/or ESL programs?
Yes
No
Are you currently working?
Yes, part-time / full-time
No
No, interested in finding a job
Are you currently going to school/college?
Yes
No
No, interested in school or college.
Are you a stay-at-home parent?
Yes
No
Are you interested in: (Check all that apply)
Tutoring
Small Group Classes
Can you meet at the Newport Beach Library for tutoring and/or classes?
Yes
No
Goals you want to work on: (Check all that apply)
Reading
Listening
Writing
How did you hear about our program?
Select answer
Online
Referral
Other
Is there anything else we need to know?
Submit