Brownsville Literacy Center 245 E. Levee St. Brownsville, Texas ...

Brownsville Literacy Center. 245 E. Levee St. Brownsville, Texas 78520. (956) 542-8080 www.brownsvilleliteracycenter.org. REGISTRATION/INSCRIPCION.
111KB Größe 11 Downloads 34 vistas
Brownsville Literacy Center 245 E. Levee St. Brownsville, Texas 78520 (956) 542-8080 www.brownsvilleliteracycenter.org REGISTRATION/INSCRIPCION Date/Fecha:

______/____ /_______

New Student/Estudiante Nuevo: ___Yes/Si

___No (When did you last study here and what was the level you completed?/¿Cuando fue su ultimo semestre, y que fue el nivel que terminó?___________

Name/Nombre:

_________________________________________________ Last Name (Apellido), First Name (Primer Nombre)

Address/Dirección:

____________________________________________________ ____________________________________________________ City (Ciudad), State (Estado) Zip Code (Codigo Postal)

Phone Number(s)/Número(s) de Telefono:

(____)_______________________ (Home/Hogar) (____)_______________________ (Work/Trabajo) (____)_______________________ (Cellular/Celular)

Sex/Sexo:____Male (Masculino) ____Female (Femenino)

Date of Birth/Fecha de Nacimiento: ____/___ /__ __ Age/Edad: ___

Marital Status/Estado Civil: ___Single/Soltero ___Married/Casado ___Divorced/Divorciado ___Widow(er)/Viuda(o) How many children do you have?/¿Cuantos hijos tiene? _________ How many people are in your household?/¿Cuantas personas viven en su casa? ______ Race/Raza (Choose all that apply./Marque todo aquel que aplique.): ___Hispanic/Hispano ___Black or African-American/Negro o Afroamericano ___American Indian or Alaskan Native/Indígena de las Americas o nativo de Alaska ___Asian/Asiático ___Hawaiian or Other Pacific Islander/Hawaiano o Isleño del Pacífico ___White/Blanco Are you currently working?/¿Esta Ud. trabajando ahorita?

___Yes/Si

___No

Are you the head of household?/¿Es Ud. la cabeza del hogar?

___Yes/Si

___No

Are you or your family receiving government assistance?/¿Recibe Ud.o su familia ayuda del gobierno?

___Yes/Si

FOR OFFICE USE ONLY/PARA EL USO DE OFICINA SOLAMENTE ___New Student

___Returning Student ID Type_________________________

Last Level Taken was ________ Status: P/NS/R1/R2 Term: F/Sp./S_________Year *Need to re-evaluate student if 2 semesters (6 mos.) have passed.

LEVEL:__________ A.M./P.M.

STAFF:_________

___No

Please choose all that apply./Marque todo aquel que aplique. ___Housing

___WIC ___TANF ___SSI __SNAP (Food Stamps/Estampillas)

___Unemployment/Desempleo

___Medicaid o Medicare ___Other/Otro:_________________

Please circle the amount closest to your annual income./Circule la cantidad mas cercana a su ingreso anual. HOUSEHOLD INFORMATION Family of 1 Person

2 Persons

3 Persons

4 Persons

5 Persons

6 Persons

7 Persons

8 Persons

$10,650

$12,150

$13,650

$15,150

$16,400

$17,600

$18,800

$20,000

$17,700 $28,300

$20,200 $32,350

$22,750 $36,400

$25,250 $40,400

$27,300 $43,650

$29,300 $46,900

$31,350 $50,100

$33,350 $53,350

$28,301+

$32,351 +

$36,401 +

$40,401 +

$43,651 +

$46,901 +

$50,101 +

$53,351 +

INFORMACIÓN DEL HOGAR Familia de 1 Persona

2 Persona

3 Persona

4 Persona

5 Persona

6 Persons

7 Persona

8 Persona

$10,650

$12,150

$13,650

$15,150

$16,400

$17,600

$18,800

$20,000

$17,700 $28,300

$20,200 $32,350

$22,750 $36,400

$25,250 $40,400

$27,300 $43,650

$29,300 $46,900

$31,350 $50,100

$33,350 $53,350

$28,301+

$32,351 +

$36,401 +

$40,401 +

$43,651 +

$46,901 +

$50,101 +

$53,351 +

Extremely Low Income Low Income Moderate Income Above Moderate Income

Ingresos muy bajos Ingresos bajos Ingresos Moderados Ingresos Sobre Moderados

How many years of education do you have?/¿Cuantos años de educación tiene?_______ Where did you study?/¿Donde estudio? ___USA

___Mexico

___Other/Otro________________

Did you finish high school?/¿Cumplió sus estudios de preparatoria? ___Yes/Si

___No

Did you attend college?/¿Asistió a la universidad? ___Yes/Si (How long?/¿Cuánto tiempo?_____)

___No

What was your course of study?/¿Cuál es su carrera? ________________________________________________________ Have you studied English before?/¿Ha estudiado ingles antes? ___Yes/Si (Where?/¿Donde?______________)

___No

___N/A

What are your goals?/¿Cuáles son sus metas? ___U.S. Citizenship/Ciudadanía de Estados Unidos ___Better job/Mejor trabajo ___Other/Otro ______________________________________________________ ** We will be taking photos throughout the school semester on different occasions in order to promote Brownsville Literacy Center. Thank you! Yes_____ No _____ ** Se tomaran fotos durante el semestre para promover la escuela en diferentes ocasiones. ¡Gracias!

SIGNATURE/FIRMA: ________________________________________________

Si ______ No ______