LVKC Tutor Information

 

 

Date:  
Mr. Mrs. Ms. Miss Program:BL  ESL   

Name: 

 *required

Address:

 *required  

City:

 *required   State:        Zip Code:
 Okay to Mail? Yes No

Home Phone:

  Okay to Call?Yes No

Work Phone:

  Okay to Call?Yes No

Cell Phone:

 Okay to Call?Yes No

 Email:

Native Language:

Other Languages Spoken:

Date of Birth:  Year: 19

Place of Birth:

U.S. CitizenYes No

Male Female

Number years in U.S.

Marital Status: Number Children:
 

Ethnic Group:

Education:

Employment Status:

Referral Name:

Annual Income:

Referral Type:

Occupation:

Available to Meet:

Instruction Preference:

Day

Morning

Afternoon

Evening

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

One-to-one small groupEither 

Student Preference:   Male  Female  Either  

Location Preference:

Transportation used:
Interests:

Special Needs:

Hearing Impaired

Physically Disabled

Wheelchair

I plan to attend all the LVKC workshops: Yes  No  I have to miss  

I commit to tutoring a minimum of 50 hours.

Applicable Non-LVKC Work/Volunteer Experiences:

Organization

Position, Duties

Date(s)

1.

2.

3.

Interests and Skills:
Writing Drawing, Art Cooking, Entertaining
Public Speaking Research Acting
Record-Keeping Typing, Clerical Accounting
Decorating Leading a Discussion Group Grant Writing
Other 
Computer Knowledge and Experience:
Fund-Raising Knowledge and Experience:
Does volunteer's employer have a matching gifts program?  Yes  No 
Volunteer positions held:
Tutor Office Library
Trainer Tester Director
Newsletter Board Member National
State Local Board Committee
Other 
Volunteer positions sought:
Tutor Office PR
Trainer Tester Director
Newsletter Computer/Data Entry Board Member
Other 

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