Student Application

If you need help filling out this application, please reach out to a Program Director. Students interested in Basic Literacy Program should email Rose.Howard@lvgh.org and those interested in ESOL Program should email Paula.Beninato@lvgh.org.

There is also an option to translate this application in the bottom right-hand corner of the page.

Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Cell Phone:*
Home Phone:
Email*
Date of Birth:*
Place of Birth:*
Are you interested in:*
- Basic Literacy Program
- English for Speakers of Other Languages (ESOL) Program
- I'm not sure
Employment Status:
Place of Employment (Previous if Retired):
Job Title:
Gender:
Ethnicity:
Race:
- Asian
- Black
- Hispanic/Latinx
- Native American
- White
- Other
Education:*
If other, please specify:
Place of Education:*
Referral Source:*
- I am a former LVGH student
- Self-referral
- Friend/Family Member
- LVGH Student
- LVGH Tutor
- College
- Library
- Employer
- Online
- Adult Ed Program
- Other
If other, please specify:
Do you receive:
- TANF (Cash Assistance)
- Disability
- SNAP (Food Stamps)
- Other
If other, please specify:
Photo Release Agreement*
- Yes, use my photo
- No, do not use my photo
I agree to let Literacy Volunteers of Greater Hartford take photographs of me and authorize LVGH, to copyright, use and publish the same in print and/or electronically. I agree that LVGH may use the photographs with or without my name and for any lawful purpose, including such purposes as publicity, illustration, advertising, and Web content.
Emergency Contact - Please provide at least one emergency contact if possible:
Name:
Relationship:
Phone:
I understand that the information on this application is subject to verification. I agree that if accepted as a volunteer, I will abide by the volunteer regulations as outlined by Literacy Volunteers of Greater Hartford.
Agreed to by:*
Date*
Date Format: MM slash DD slash YYYY