Student Application
Please fill in all fields marked with a *
First Name *
Last Name *
Email Address *
Username you would like to use *
Street Address
City
State
Zip
Gender Male   Female
Home Phone
Cell Phone
Goal / Expectations
What I need help in
Education
Are you a student?

Yes
No

What are you studying? English
College
Trade School
What is your major area of study?
Do you need help specific to your studies? Yes No
Is so, explain:
Employment
Employed Yes
No
Place of employment
Do you need help specific to your job? Yes No
Is so, explain:
Referred by
Times Available
  Monday Tuesday Wednesday Thursday Friday Saturday
Morning
Afternoon
Evening
Information Requested for funders:
Economically Disadvantaged
Please select "Yes" if your income is below the stated figure for your family saize (number in family).
Yes No
Number in Family 1 2 3 4 5 6 7 8
Annual Income $10,830 $14,570 $18,310 $22,050 $25,790 $29,530 $33,270 $37,010

    If you have more than eight (8) family members, add $3,740 to each for each additional household member.
Ethnic Origin
Asian Hispanic African American
Native American Caucasian / White Other
Regional Origin
Middle East Eastern Europe Western Europe
North America Central / South America Africa
Mexico Asia Other
 
Country of Origin:
Do you have any disability? Yes No

If yes, please explain:
Have you ever been convicted of a felony? Yes No
(This is a question asked of students and tutors for purposes of successful matching and is relevant only in terms of how it relates directly to the tuoring arrangement.) If yes, please discuss this with the program coordinator when interviewed.
I authorize the release of my testing scores. Yes No

              

Marathon County Literacy Council
300 N. 1st St., Wausau, WI 54403 | Phone: 715-261-7292
Fax: 715-261-7232 | email: info@mcliteracy.us
Marathon County Literacy Council, Inc. Home page link