Full Name * Street Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Mobile Phone Number * Alternate Phone Number Email * Gender * Male Female Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Employment Status * - Select -RetiredWorks part-timeWorks full-timeNot employedStudentOther If Other, please describe Area of Work Experience Years of Education * - Select -High School/GEDSome CollegeAssociate's DegreeBachelor's DegreeMaster's DegreeDoctoral Degree Which program would you like to work with? * Adult Basic Education English as a Second Language Elementary-Middle Literacy High School Literacy Check all that apply. Special Skills or Interests * Tutoring Availability * ABE & ESL tutoring takes place during library hours: Mon-Wed 9A-9P, Thurs 9A-6P, Fri-Sat 9A-5P. Youth Literacy tutoring takes place during school hours. Emergency Contact * Emergency Contact Phone * Relationship * Have you ever been convicted of an offense against the law other than a minor traffic violation? * - Select -YesNo If Yes, please explain. A conviction does NOT mean that you cannot volunteer. How did you hear about us? * Photo Release * I agree to the statement below I do not agree to the statement below. Please do not use my image. I agree to grant to RCLC and its authorized representatives permission to use photos and/or video images of my participation. I further agree that any or all of the material photographed may be used in any form, as part of any future publications, brochures, or other printed or online materials used to promote RCLC, and further that such use shall be without payment of fees, royalties, special credit or other compensation. Signature * Please type your name to certify that all information submitted is true and correct. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
