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 ______
