Family Literacy Registration

Family Literacy Program

Interested in joining the family literacy program? Please fill out the form below or you can download and print the form by clicking the button below and bring it in to the library. If you need help filling out the form please come into the library.

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Family Literacy Program
Mariposa County Library
Registration/Application

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Photo ID Number *

Date of Birth *

Special needs or accommodations? (e.g. learning disability, hearing loss, non-English speaking etc.). *

Emergency Contact Information *

Ethnicity (optional information) *

Where did you hear about this program? *

Referring Agency/Contact Name, if applicable: *

Part 1: Verification of Truth
Have you ever had a behavioral warning or incident report filed about you at any Mariposa County Library?
I verify that I have not had any behavioral warnings or incident reports filed about me at any
Mariposa County library. The information that I am providing throughout this pre-assessment
screening is true and correct. I understand that providing any false or misleading information in
this document or at any point during my participation in the Mariposa County Library's Adult
Literacy Program establishes grounds for immediate dismissal from the program.

Please check the box below and fill out your name. This is considered an online signature and verification of the above statement *

Agreement

Name *

First

Last

Part 2: Background Information

Tell us about the children in your home, including their names and ages. *

Tell us about parents' Educational background: *

What language is mainly spoken at home *

Is there anything else you would like us to know about you and/or your family? *

Part 3: Goals

Please tell us about your reason for wanting to participate? *

Submit

Family Literacy Program

​Family Literacy Program Mariposa County Library ​Registration/Application

Part 2: Background Information​

Part 3: Goals

Family Literacy Program
Mariposa County Library
Registration/Application

Part 2: Background Information