Adult Literacy Program Interest & Referral Form
Share your contact details, the support you need, and how you heard about the program.
About You
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Phone
Text
Email
Best Time to Contact You
Morning
Afternoon
Evening
SECTION 2 — What Support Do You Need?
Adult Basic Education
GED / High School Equivalency Preparation
English Language Acquisition
Reading Support
Writing Support
Math Support
Digital/Computer Literacy
Workforce Readiness
Other
Other
SECTION 3 — Your Goal
Education Background
Highest level of education completed
*
Did not complete high school
High school diploma
GED/HSE
Some college
Other
Currently preparing for GED/HSE
*
Yes
No
Not sure
Digital Literacy
How comfortable are you using a computer?
*
Not comfortable
Somewhat comfortable
Comfortable
Very comfortable
Workforce Readiness
Would you like help preparing for employment?
*
Yes
No
What kind of workforce readiness support do you need?
Resume
Job applications
Interview preparation
Computer/job-search skills
Workplace communication
Other
Availability
Preferred Program Schedule
*
Morning
Afternoon
Evening
Saturday
Preferred Instruction Format
*
In person
Online
Hybrid
No preference
Referral Source
How did you hear about Impact The Future?
*
Friend/family
Church
Library
School/adult education
NCWorks/workforce organization
Community organization
Social media
Flyer
Partner organization
Other
Consent
☐ I understand that submitting this form expresses interest in Impact The Future and does not guarantee enrollment. A program representative will contact me regarding next steps.
Submit
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