Nashua ALC Registration Form - Tutoring Program (2023-2024)

Nashua ALC Registration Form - Tutoring

Please complete all information and click SUBMIT at the bottom of the page. A staff member will contact you within 1 week after you submit the form to complete the registration process. Students are required to live or work in New Hampshire to qualify for class. If you have questions or need assistance completing this form, contact the Coordinator at 603-716-7017 or email mhuard@nashuaalc.org.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Can we text you at this number?*

YesNo
Email*
example@example.com
What is the best way to contact you?*

TextCallEmail
Birthdate*

MonthDayYear
Date
Gender*
What country were you born in?*
What is your first language?*
Are you Hispanic or Latino?*

YesNo
What is your race or ethnicity? (Check all that apply.)*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
How many years did you go to school?*
Where did you complete your schooling?*

In the USOutside of the US
Do you have a high school diploma?*

YesNo
If yes, what is the name of your high school?
Do you have a university or college degree or specialized training certificate?*

YesNo
If yes, what is the name of the school?
Are you currently enrolled in or attending a different school (high school or other)?*

YesNo
If yes, what is the name of the school?
Are you currently employed?*

YesNo
Are you looking for work?*

Yes, I am looking for work.No, I am not looking for work.No, I am retired.
If you are working, what is the name of the company or industry?
How many hours (about) do you work per week?
Do you have any barriers to employment? (Check all that apply.)*

Cultural barriersDisabledDisplaced homemakerLow incomeEx-offenderExhausting TANF within 2 yearsHomelessLong term unemployedMigrant farm workerSeasonal farm workerSingle parent or guardianNone
Are you currently working with any of the following Employment Security programs? (Check all that apply)*

Wagner-PeyserTrade Adjustment AssistanceJobs for VeteransUnemployment InsuranceTANF/NHEPNone
Are you currently working with any of the following Office of Workforce Opportunity programs?*

WIOA AdultWIOA Youth/NH JAG/My TurnDislocated Worker (Title I)SCSEP/National AbleNone
Are you currently working with any of the following Department of Education programs?*

Voc RehabCareer and Tech. Ed.Community College Systems of NH (WorkReady NH, ApprenticeshipNh, Certificate and degree program at the Community CollegesAdult Education other than this center - please type name of program below:NoneOther
Classes and tutoring for the 2024-2025 school year will be offered online or in-person at convenient community location.
Have you taken class with the Adult Learning Center before?*

YesNo
When do you want to meet with a tutor? You can check more than one.*

MorningAfternoonEvening
How do you want to attend tutoring?*

In-personOnlineEither In-person or Online is fine
Do you have access to any of the following technology to use for learning or tutoring? (Check all that apply.)*

Computer with CameraComputer without CameraWebcamHeadset with microphoneMobile PhoneHome PhoneInternet AccessPrinterScannerNone
How comfortable do you feel using technology?*
Is there anyone (parent, child, case worker, etc.) you give us permission to talk to about your education? (If yes, please list.)
Is there anything else we should know about you? (For example: medical issues, learning difficulties, classroom comfort needs, etc.) This question is optional.
Privacy Policy and Statement of Confidentiality

I understand that my information will be treated as confidential and used only for educational purposes. It will be seen only by education staff members who are required to treat all student information as private. If you agree, please sign below using your mouse or finger.
Signature*

Clear
Release of Information Form

Please read through the NH Works System Partners Release of Information form. If you agree, please sign below using your mouse or finger.
I have read the release of information form and agree to share information with NHWORKS partners.
Signature

Clear
Staff Notes
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