LEAP Application

Literacy for Every Adult Program
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home Number*

Area CodePhone Number
Cellular Number

Area CodePhone Number
Gender*
Birth Date*

MonthDayYear
Marital Status*
Emergency Contact*

NameNumber
Employment*

EmployedUnemployedNot Empolyed/ Not Seeking WorkRetired
Highest Grade Completed*

4567891011HS DiplomaGED/ProficincySome College
Did you go to school in the United States?*
Ethnicity*

American Indian/Native AmericanAsianBlack/African-AmericanHispanic/LatinoPacific IslanderWhite/AngloOther
Other:
Is English your native language?*

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

YesNo
If yes, what is the agency?
What is the name of your case worker?
*******************************
Which program are you interested in?

GED PrepAdult Basic EducationComputer BasicsEnglish as a second Language
When are you available?*
Do you take medication?*

YesNo
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?

YesNo
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