York Literacy Institute Student Intake
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First Language. If you do not want your paper work in your first language, please  also tell us what language you would prefer. *
Write names of anyone else testing with you.
First Name *
Last name *
Phone Number (xxx-xxx-xxxx) *
Do you receive texts at the above number? *
Address. ex) 500 Maywood Road.  *
City, State Zip Code  Ex) York, PA 17402 *
Email address *
County (not Country) you currently live in.

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School District you currently live in/ where your children attend/ would attend school  *
Birth Date *
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Date of arrival in the US. US Citizens, write 00/00/00. *
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DD
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Why are you  participating in English classes? *
How did you hear about YCLC?  List name or organization in the next question
 *
Name of Person, Place or Business from  Above 
Ethnicity *
Race *
Country of Birth *
Gender *
Gender Identity (optional)
Clear selection
What are your preferred pronouns? (optional)
Clear selection
I work...... *
Who is your employer? *
Does your employer provide health benefits? *
Do you receive public assistance?  If yes, which ones: *
Marital Status *
Total Number Living in Household *
Number of Dependents Under 18 years Of Age in Household *
Household Status *
Annual Household Income *
What is the highest level of education that you HAVE COMPLETED? *
Name of the last Pennsylvania school attended (if you did not attend school in PA, write NONE to continue) *
Did you attend: *
Have you ever been enrolled in Special Education classes? *
Have you ever enrolled in HSE/ESL classes? *
Are you a/an....

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 ( more or less house wife or house husband) 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
 *
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 *
Exhausting TANF- a person within 2 years of exhausting lifetime eligibility (total of 5 years) *
Foster Care Youth - a person who is currently in foster care or has aged out of the foster care system *
Homeless individual- a person without a fixed, regular and adequate nighttime residence or runaway youth. This is not living with friends, family or in a hotel.  *
Individual with disability - a person with a physical or mental impairment that substantially limits one or more of the persons major life activities *
Long-term unemployed - a person who has been unemployed for 27 or more consecutive weeks in the US *
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 *
Single parent - a person who is single, separated, divorced, or a widow and has primary responsibility for one or more dependent children under age 18 or is currently pregnant *
Have you ever been convicted of a felony? *
If yes to the above question, please explain. When?  If no, please enter NONE to continue *
Have you ever been convicted of a crime of violence? *
If yes to the above question, please explain. When?  If no, please enter NONE to continue *
Do you need any special educational accommodations in the classroom  in order to learn? *
If yes to the above, please explain.  If NO, enter NONE to continue *
First and LAST name  of emergency contact *
Phone number of emergency contact *
Relationship to emergency contact *
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