4. Student Interest Form
Student Contact Information
First Name
Last Name
Street Address
City
State
Zip Code
Date of Birth
Primary Phone
Other Phone
Email Address
How did you hear about Literacy KC?
Please select...
Case Worker
Church
Community Organization
Dept. of Corrections
Doctor
Employer
Facebook
Family Member
Flyer
Former Student
Friend
Internet/Search Engine
Library
Newspaper
Other
Phone Book
Radio
School
Social Service Agency
Speaker
Special Event
Student
Television
Which Program are you interested in joining?
Please select...
High School Equivalency
ELL
Digital
Excel Online High School
Comments
Other information that staff should know about this potential new student.
x
Contact Information
Literacy KC
3036 Troost Ave. | Kansas City, MO 64109
www.literacykc.org
|
info@literacykc.org
main: (816) 333-9332 | fax: (816) 444-6628