Title:  Mr.  Mrs.  Ms.  Miss

Name: 

Mailing Address: 

City: 

Zip Code: 

Telephone

Home: 

Work: 

Email: 

How did you hear about our program?

Which workshop would you like to attend? (Training Schedule)  

1st Choice:  January February March April Daytime April Evening June July August September October November None

2nd Choice:  January February March April Daytime April Evening June July August September October November None

Do you have any children living at home?  Yes  No

In what part of Tulsa (or surround area) do you live?  (For example, southwest, east, northeast)? 

Gender:  Male  Female

Date of Birth:  / /   mm/dd/yyyy

Ethnicity: 

Please choose the highest educational level completed:  ----------------------------- Graduate School Undergraduate Some College High School Dipolma GED Less than 12th Grade Other

Employment Status:  ----------------------------------------- Full-time Part-time Retired Unemployed, Seeking Work Unemployed, Not Seeking Work Other

Occupation:  (If retired or currently not in the job market, please indicate professional background.)

Employer: 

What days are you available to tutor?

Monday  Tuesday  Wednesday  Thursday  Friday  Saturday  Sunday

What time of day are you available to tutor?

Morning      Afternoon     Evening

At what libraries are you willing to meet?

Which would you prefer?  Beginning Reader  More Advanced Reader

Comments: 

Would you like to work with a special needs student?  Yes  No

If yes, which special needs student would you prefer?

English as a second language     Developmentally Disabled

Adjudicated Juvenile/Adult          Physically Handicapped

What are your special interests (e.g. fishing) or skills (e.g. sign language)?

Have you tutored in an adult literacy program before?  Yes   No

Explain what you hope to achieve as a tutor in the Library's Adult Literacy program.

Have you worked with children before?  Yes   No

If yes, in what capacity? 

Are you involved in other volunteer activities?  Yes    No

If so, please list those organizations: 

Are you a Tulsa Community College student taking this course for credit?  
Yes  No

Once you have completed the form, place a checkmark in the box below and then click on the submit button.  If you would like to erase the form and start over, click on the reset button below.