LEAP Application

Literacy for Every Adult Program
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail
Home Number *

Area Code Phone Number
Cellular Number

Area Code Phone Number
Gender *
Birth Date *

Month Day Year
Marital Status *
Emergency Contact *

Name Number
Employment *

Employed Unemployed Not Empolyed/ Not Seeking Work Retired
Highest Grade Completed *

4 5 6 7 8 9 10 11 HS Diploma GED/Proficincy Some College
Did you go to school in the United States? *
Ethnicity *

American Indian/Native American Asian Black/African-American Hispanic/Latino Pacific Islander White/Anglo Other
Other:
Is English your native language? *

Yes No
If no, please specify
What language do you speak at home?
Is another agency requiring that you attend LEAP? *

Yes No
If yes, what is the agency?
What is the name of your case worker?
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Which program are you interested in?

GED Prep Adult Basic Education Computer Basics English as a second Language
When are you available? *
Do you take medication? *

Yes No
If yes, what are you taking?
What effect does the medication have on you?
Do you have children at home under the age of 16?

Yes No
If yes, how many?
If you have children, what are your families interest?
There are occasions when filming is done or photographs are taken during classes, field trips and special events. I give my consent to the City of Richmond to take and use any film or photos of myself without restriction and compensation.
Signature *
Date *
Should be Empty:

Literacy for Every Adult Program

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There are occasions when filming is done or photographs are taken during classes, field trips and special events. I give my consent to the City of Richmond to take and use any film or photos of myself without restriction and compensation.