Touch Gift Foundation® Student General Interest Form

General Interest Form

Welcome -

We are so excited that you are expressing interest in our Educational Services!

We are available to see how we can partner with you in

1) improving your life through literacy and/or

2) working towards completing High School.

Our services is designed to support your need.

Please complete the general interest form and our staff will follow-up with you on Tuesdays or Thursdays from 10:00 am - 2:00 pm.

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* 1. First Name

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* 2. Last Name

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* 3. What is a good telephone number to call regarding our programs and making appointments?

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* 4. Through what email address can we reach you? This is only to get in touch, not to send spam.

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* 5. What is your marital status?

Single

Married

Widowed

Divorced

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* 6. Please identify your primary racial or ethnic group?

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 7. Please check one:

Not Disabled

Documented Disability as Defined by ADA

Chooses not to Disclose

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* 8. How did you learn about Touch Gift Foundation® programs?

Child Care Society

Near West American Job Center (National Able Network)

Illinois Department of Employment Securities (IDES)

Illinois Department of Human Services (IDHS)

Bessie Coleman Library

One-Stop Operator

Other (please specify)

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* 9. Please provide your home address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

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* 10. Do you or a dependent (example: your child) receive public assistance?

Yes

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* 11. What are your barriers to employment?

Homelessness

Displaced Homemaker

Currently in a correctional facility

Currently in a Community Correctional Program

Ex-Offender

English language learner, low literacy levels

Low income

Individual with a disability

Single parent

Long-term unemployment

Exhausting TANF within 2 years

Youth

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* 12. Program Interest, check all that apply:

Improve Reading and/or Writing Skills

Improve Math Skills

Improve Digital Literacy (Computer Navigation)

Complete High School

English as a Second Language