Adult Intake Form

Literacy Central Vancouver Island
Adult Learner Intake Form
Name

First NameLast Name
English Name (if applicable)
ADDRESS
Street
City
Postal Code
CONTACT DETAILS
Phone
Cell
Email
example@example.com
EMERGENCY CONTACT
Name
Phone Number
This information below is collected to help us run better programs and obtain funding. NO personal information will be shared outside LCVI.
Age Group
Gender
Pronoun(s)
Status in Canada
Employment Status
Career
Education Level
How did you hear about us?
LEARNING GOALS
Services Interested In

One-to-One TutoringGroup Classes / WorkshopsSocial EventsIn Person (LCVI)Online
Learning Goals
AVAILABILITY
Is there anything that could interfere with your ability to meet with your tutor?

YesNo
If yes, please explain
What days work best for you to learn?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What time of the day works best to meet?

Morning (9am - 12pm_Afternoon (12pm - 5pm)Evening (5pm - 8pm)
Your skills and interests:
Do you have any learning needs or challenges/diagnosis that you want to declare:
I agree to be registered in your database and placed on your waitlist or in a learning program. When registered I agree to share my contact information with my Volunteer Tutor or Program Leader:
Sign
Date

MonthDayYear
Date
Sharing of Assessment Information With Tutor
Literacy Central Vancouver Island (LCVI) provides literacy, ESL and numeracy assessments for our learners. The assessments completed by learners are not used for diagnosis. The assessments provide LCVI with a general knowledge of the learner’s English language ability and level. This information is then used to pair LCVI learners with a tutor they feel will best meet the needs of the learner(s). A copy of the assessment results would also be provided to the tutor for the purpose of planning and preparation; setting short and long term goals for the learner(s).
I understand that Literacy Central Vancouver Island will be conducting an assessment. A copy of the assessment results will be used for pairing the learner(s) with a tutor.

I consent to Literacy Central Vancouver Island sharing a copy of the assessment results with the tutor for the purpose of planning and preparation; setting short and long term goals for the learner(s)I do not consent to Literacy Central Vancouver Island sharing a copy of the assessment
Signature
Date

MonthDayYear
Date
Adult Learner Agreement

By enrolling in theone-to-one Tutoring Program, I agree to the following:
- I will come to my tutoring sessions as scheduled and on time.
- If I cannot attend, I will call my tutor ahead of time (the day before, if possible)
- If I am unhappy with my tutor or my lessons, I will let the Adult Literacy Coordinator know so that other arrangements can be made (phone 250.754.8988 or email adult.learning@lcvi.ca)
- If I decide to stop tutoring, I will let both my tutor and the Adult Literacy Coordinator
Signature
Date

MonthDayYear
Date
Should be Empty:

Literacy Central Vancouver Island

Adult Learner Intake Form

ADDRESS

CONTACT DETAILS

EMERGENCY CONTACT

LEARNING GOALS

AVAILABILITY

Sharing of Assessment Information With Tutor

Adult Learner Agreement