York Literacy Institute Student Intake  York County Literacy Council   Konsey Alfabetizasyon nan  York ak admisyon etidyan nan Konsey Alfabetizasyon sila a
All information is treated as confidential unless your written permission is given. / Tout enformasyon yo rete sekrè defi ou pa bay pemisyon ekri pou patage yo.
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First language/ Premye lang ou pale     *
List names of anyone else testing with you./Tanpri lis non nenpòt lòt moun k ap fè tès avèk ou.
First name / Premye non: *
Last name, Family name / Siyati, non fanmi:  *
Phone Number/ Nimewo telefon (xxx-xxx-xxxx) *
Do you receive texts at the above number?/ Èske w resevwa tèks nan nimewo ki anwo a? *
Address / Adres  Ez) 500 Maywood Rd

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City, StateZip Code/  ak vil, eta, ak Kod postal Ez) York, PA 17402
Email address/Adres imel *
County (not country) you currently live in *
School District you currently live in.  Distri lekòl ou abite kounye a/ak kote pitit ou yo ale lekòl/ta prale lekòl la *
Birth Date (Month, Day, Year)/Dat ou fet (Mwa, jou, ane) *
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DD
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Date of arrival in the US. US Citizens, write 00/00/00./ Dat ou rive  Etazini. Sitwayen ameriken, ekri 00/00/00.      *
MM
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DD
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YYYY
Reason for Participating in Adult Education/ Rezon pou Patisipe nan Edikasyon Pou Granmoun *
How did you hear about YCLC?  Please write the name or organization in the next question. / Ki jan ou te tande pale de YCLC? Tanpri ekri non an oswa òganizasyon an nan pwochen kesyon an. *
Name of Referral Source Above (if self, enter 'self' to continue)/   Non Referans Sous Pi wo a (si w te rentre ak  pwop tet ou, jus kontinye)/ *
Ethnicity/Etnisite *
Race/ Ras/ *
Country of Birth/ Peyi ou fet   *
Gender/ Seks *
Gender Identity (optional)/ Idantite sèks (opsyonel)
Clear selection
What are your preferred pronouns? (optional)/ Ki  pwonon ou pi pito? (opsyonel)    
Clear selection
I work...../  mwen travay.... *
Name of Employer/ Non employè ou a/konpayi
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Does your employer provide Health Benefits?  Eske anplwaye ou la bay Benefis Sante?
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Do you receive public assistance?  If yes, which ones:/ Eske ou resevwa asistans piblik?  Si wi, kisa li ye   *
Marital Status/ Eta Sivil ou *
Total Number Living in Household/ Kantite moun au  total ki ap viv nan kay *
Number of Dependents Under 18 years Of Age in Household/ Kantite moun ou responsab ki Poko gen 18 lane ki nan kay la *
Household Status/ Situation Moun Nan Kay La *
Annual Household Income/ Revni anyel pou kay *
Did you receive?/Eske ou te resevwa? *
Name of the last Pennsylvania school attended (if you did not attend school in PA, write NONE to continue)/ Non denye  lekol nan Pensylvania ou te frekante  (si ou pa t ale lekol pensylvania, ekri okenn pou kontinye) *
Did you attend:/ Eske ou te ale: *
Name of post secondary school if answered yes above (if no, enter NONE to continue)/ Non lekol apre etid klasik saa siw te  reponn wi anwo a (si non, antre  OKENN epi  kontinye) *
Have you ever been enrolled in Special Education classes?  Eske ou te janm enskri nan klas edikasyon espesyal? *
Have you ever enrolled in HSE/ESL classes? Eske ou te janm enskri nan klas HSE/ESL? *
Are you a..../ ou se yon

Displaced Homemaker - a person who has been providing unpaid services to family members in the home and who has been dependent on the income of another family member but is no longer supported by that income OR is the dependent spouse of a member of the Armed Forces on active duty AND is employed or underemployed and is experiencing difficulty in obtaining or upgrading employment/  Sevant ki Deplase -yon moun ki tap bay sevis san touche lajan a manm fanmi yo ki nan kay la e ki te depann de revni yon lot manm fanmi e ki pa sipote pa revni sa a anko  oswa se yon mari ki responsab yon manm fos lame a sou devwa aktif epi ki ap travay oswa ki pa gen gro travay e li gen  difikilte pou jwenn oswa amelyore travay li (plis oswa mwens madanm kay oswa mari kay)
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Ex-offender - a person who either has been subject to any stage of the criminal justice process or requires assistance in overcoming artificial barriers to employment resulting from a record of arrest or conviction/se Homemaker-Ansyen delinkan- yon moun ki te fe obje de nemport ki etap nan justis penal la oubien ki bezwen ed pou sumonte difikilte jwenn travay akoz yon dosye arestasyon oubyen kondanasyon *
Exhausting TANF- a person within 2 years of exhausting lifetime eligibility/ Epuizman TANF-yon moun apre 2 ane epuizman elijibilite pou la vi ( total de 5 ane) *
Foster Care Youth - a person who is currently in foster care or has aged out of the foster care system/  yon moun ki pèdi fanmi yo epi ki rete ak yon lòt fanmi gouvènman an te deziyen  Jenn ki nan fanmi akey-yon moun ki  nan swen adopsyon kounye a  oswa ki vyeyi an deyo  sistem swen adopsyon an *
Homeless individual- a person without a fixed, regular and adequate nighttime residence or runaway youth/Moun ki Sanzabri-yon moun san yon rezidans fiks, regilye ak lannuit oswa jen kidezète lakay li.  Sa a se pa k ap viv ak fanmi, zanmi oswa nan yon otèl. *
Individual with disability - a person with a physical or mental impairment that substantially limits one or more of the persons major life activities/Moun ki gen andikap - yon moun ki gen yon pwoblem fizik oswa mantal ki limit anpil youn oswa plis nan aktivite prensipal nan lavi moun saa *
Long-term unemployed - a person who has been unemployed for 27 or more consecutive weeks/ Moun ki nan chomaj lontan-yon moun ki genyen 27 semèn yonn dèyè lot oubyen plis. *
Low-income individual - a person who within the last 6 months has received income-based assistance, such as housing supplement or food stamps, or whose total family income is below 70 percent of the lower living standard income level/Moun genyen revni ki ba-yon moun ki nan denye 6 mwa  yo te resevwa asistans revni ki baze sou, tankou sipleman lojman oswa koupon pou manje, oswa ki gen revni familyal total ki anba a 70 pousan nan nivo revni ki pi ba estanda *
Single parent - a person who is singe, separated, divorced, or a widow and has primary responsibility for one or more dependent children under age 18 or is currently pregnant/ paran ki sel-yon moun ki selibate, separe, divose, oswa yon vèv e li gen responsablite prensipal pou youn oswa plis timoun anba laj 18 an oswa ki ansent kounye a *
Have you ever been convicted of a felony?/Eske ou te  kondane pou yon yon krim deja? *
If yes to the above question, please explain. When?  If no, please enter NONE to continue/Si wi pou kesyon ki anwo la a, tanpri eksplike.  Kilè ? Si non, tanpri antre PA /okenn kontinye *
Have you ever been convicted of a crime of violence?/Eske ou kondane  pou yon krim vyolans deja? *
If yes to the above, please explain. When? /Siw reponn wi pou pi wo a, tanpri eksplike.  Kilè?  If No, please write 'None'  kontinye // Si non, tanpri ekri ' okenn '. *
Do you need any special accommodations?/Eske ou bezwen yon akomodasyon  edikasyon  espesyal  nan salklas la  aprann/ *
If yes to the above, please explain.  If NO, enter NONE to continue/Si wi pou pi wo a, tanpri eksplike.  Si non, antre nan OKENN kontinye *
First and LAST name of emergency contact/premye ak SIYATI kontak ijans *
Telephone number of emergency contact/nimewo telefòn  kontak ijans *
Emergency contact relationship to you / Relasyon kontak ijan avèk ou *
This is to certify that that the information provided above is accurate to the best of my knowledge.   /Sa a se sètifye ke enfòmasyon yo bay pi wo a egzat dapre sa mwen konnen.
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