Volunteer Information
*First Name *Last Name

(H) (W) (C)

Street Address 1
Street Address 2
City State Zip Code

*E-mail address

Placement Advisor Choose from the list of PAs below Elise Bruml Steve Cristofar Anne Jillson Ann Poad Jan Auerbach Tracy Tapscott

Has tutoring ended?
Yes No
If yes, date ended?

Reason tutoring ended

If you are not presently tutoring, are you available to tutor?
Yes No

Does the student need another tutor?
Yes No

Would you like to be contacted to discuss other volunteer opportunities? Yes No

Student Information (if tutoring a group, please give the location and number of students instead)
First Name Last Name

Please fill out if changed:
Home Tel. Work Tel.

Street Address 1
Street Address 2
City State Zip Code

Jurisdiction
Arlington
Alexandria
Fairfax
Other (please specify)

I. VOLUNTEER HOURS

Total tutoring hours for this quarter
Tutor preparation and travel time
Trainer (include preparation & travel time)
Placement advisor/student interviewer
Workshop registration, in-service help
Board member
Other hours, please specify

II. BOOK LEVEL AT END OF QUARTER

Laubach Way to English
Level

Life Prints
Level

Literacy Plus
Level

Side by Side
Level

Other materials used:

III. COMMENTS
Please share how tutoring has affected you and your student, skills you are currently working on, or any special comments or concerns you may have.

IV. LIFE IMPROVEMENTS AND ACHIEVEMENTS (check any that apply)
Self confidence
Got a job
Job performance/advancement
Got a driver's license
Got a library card
Registered to vote
Entered ESOL class
Acquired citizenship
Other (please specify):

V. PERSONAL LEARNING GOALS:
Please CHECK AT LEAST 3 goals that your student is currently working on. If a goal has been achieved this quarter, please check that box. Feel free to write in other goals.

SELF AND COMMUNITY
Working    Goal
On    Achieved
   1. Reply to request for personal information (name, address, phone number, social security number).
   2. Read/write own name, address, telephone number, and social security number
   3. Ask for and tell the time
   4. Read a calendar
   5. Find name in telephone directory
   6. Use the telephone
   7. Phone 911 emergency
   8. Record and write simple telephone messages
   9. Read and interpret food labels
   10. Identify names and value of U.S. currency
   11. Determine correct change for purchases
   12. Describe ailments/symptoms
   13. Read labels/directions on medicine bottles
   14. Use a map to find a destination
   15. Read traffic signs and street names
   16. Ask for location of items in a store
   17. Use bus/metro schedule
   18. Ride bus/metro to destination
   19. Read Bible or other religous material
   20. Read newspaper or magazine articles
   21. Read a bill
   22. Write money orders or checks
   23. U.S. citizenship exam

FAMILY
Working Goal
On Achieved
   24. Read to children
   25. Help children with school work
   26. Speak with school personnel
   27. Read/write notes to/from child's school

WORK
Working Goal
On Achieved
   28. Fill out job application
   29. Read work-related materials
   30. Fill out work forms
   31. Pass a work-related test

OTHER