Prospective Tutor Intake Form

For information on requirements for Broome-Tioga Literacy Volunteer Tutors, please click here.  Print this form, fill it out and send it to:   Literacy Volunteers of Broome and Tioga County, 130 W. Main St, Endicott, NY  13760

DATE: _____________ CALL TAKEN BY: __________

 PROSPECT NAME:      ____________________________________________________________

 ADDRESS:                       ____________________________________________________________
                                        

 PHONE (HOME)           __________________  WORK ________________  CELL_____________

e-mail address:         ________________________________Birthdate_____________________

THERE ARE SEVERAL VOLUNTEER OPPORTUNITIES AVAILABLE. _____TUTORING _____EVALS _____OFFICE _____PHONE  _____ BOARD MEMBER _____ OUTREACH       _____ OTHER

TUTORS MUST BE OVER THE AGE OF 18 AND ABLE TO READ AT A 12TH GRADE LEVEL.

ARE YOU ABLE TO ATTEND AN 18-HOUR WORKSHOP FOR EITHER BASIC OR ESOL LITERACY TRAINING
_____YES _____NO

 TUTORS SHOULD BE SENSITIVE, RESPECTFUL AND ABLE TO WORK ONE-ON-ONE WITH A STUDENT.

ARE YOU ABLE TO MEET AN APPROVED TUTORING SITE?   ____YES ____NO

       (Home tutoring is not approved).

 HOW DID YOU HEAR ABOUT LVA? _____________________________________________

   LVA SERVICES ARE FREE OF CHARGE TO STUDENTS. 

THERE IS A $40.00 FEE TO TUTORS TO HELP DEFRAY COSTS.

       WOULD YOU LIKE TO RECEIVE NOTICE OF OUR NEXT ORIENTATION? ___YES ___NO INFO:_______________________________________________

 DO YOU NEED ANY SPECIAL ACCOMMODATIONS FOR TUTOR TRAINING? ___Y ___N

I have reviewed this sheet with the prospective Tutor.  ______________(Initials).  

Literacy Volunteers believes that all individuals should have access to and be given the opportunity to participate in its programs without regard to race, religion, color, gender, marital or familial status, age, national origin, political beliefs, pregnancy, sexual preference, disability, or any other unlawful basis.