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 Carol Ashworth Ted Brown Kay Habeger Tom Lorenzo Sandra Scott Peggy Shomette Noel Sipple Jackie Woodle Jill Sullivan

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 (or group's location)
Last Name
Middle Initial (or number of student's in group)

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

Street Address 1
Street Address 2
City State Zip Code

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 Reading
Level

Challenger
Level

Wilson
Step

Reading for Today
Level

Voyager
Level

Other materials used:

III. ENGLISH SKILLS
What skills in understanding, speaking, reading, and/or writing English did you work on this quarter? What progress did your student make in these areas? (e.g., worked on grammar, student can now write/use correctly the past tense of regular and irregular verbs)

IV. If your student was employed at the beginning of the quarter, is he/she still employed?    Yes No

V. Did your student get a job this quarter?   Yes No

VI. If your student is a citizen, did he/she register to vote or vote for the first time this quarter?   Yes No

VII. PERSONAL LEARNING GOALS/LIFE ACHIEVEMENTS
Please list any achievements your student made this quarter. If a category is not appropriate for your student this time, leave it blank. Write each achievement on its own line under the most appropriate category. Mark the “Achieved” circle if the goal has been achieved. Mark the “Working on” circle if your student made progress toward that goal but didn’t completely achieve it. If you are unsure in which category to place an achievement, put it in the category which best fits your individual student’s learning goals. For example, if the student learned how to read a bus schedule in order to go to the doctor, enter “read a bus schedule” under the “Health” category. However, if the student did so to get to job interviews, place it under the “Entered Employment” category. Do not include achievements that occurred before tutoring began or if you have included them in previous quarterly reports unless your student accomplished them at a higher level this quarter – e.g. read a harder book, wrote a detailed note to a child’s teacher.

Looked for employment (e.g., filled out job application, read job ads):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Advanced employment (e.g., filled out work form, passed work-related test, got promoted):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Citizenship (e.g., submitted application for naturalization, passed citizenship test, voted):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Entered other education or training (e.g., enrolled in GED class, participated in vocational training course):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Financial/consumer skills (e.g., made change, wrote check, applied for a credit card):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Increased involvement in child’s learning (e.g., read to a child, wrote note to teacher, helped a child with homework, replied to child’s report card):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Family (e.g., planned a trip, participated in extracurricular activities):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Health (e.g., described ailments, read medicine label, filled out insurance form):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Personal (e.g., wrote a letter to a friend or business, got a library card, read a book):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

VIII. Has your student experienced any intangible improvements this quarter which might be connected to improved English (e.g., increased self-confidence)?

IX. Please share how tutoring has affected you or your student or any special comments or concerns you may have. Do you need additional materials? How can we assist you in your tutoring?