Learner Interest Form

Name/Nombre:

Name/Nombre:

Address/Dirección:

Address/Dirección:

Street Address/Dirección

City/Ciudad

Zip Code/Código Postal

Phone Number/Número de Teléfono:

Phone Number/Número de Teléfono:

Email/Correo electrónico:

Email/Correo electrónico:

Highest Level of Education/Nivel más alto completado en la escuela:

Highest Level of Education/Nivel más alto completado en la escuela:

Do you have children?/Tiene usted hijos?

Do you have children?/Tiene usted hijos?(Select an Answer) Yes/Sí No/No

Please list the names and ages of your children/Por favor, escriba los nombres y las edades de sus hijos:

Library nearest to you/Biblioteca más cercana a usted:

Library nearest to you/Biblioteca más cercana a usted:(Select an Answer) Marina Carmel Valley Castroville Soledad Seaside King City Harrison Memorial (Carmel)

The following information is collected to help us in reporting program-wide data for the State Library and other funders. It is never reported individually and is kept confidential. Thank you for your help.

The following information is collected to help us in reporting program-wide data for the State Library and other funders. It is never reported individually and is kept confidential. Thank you for your help.

Date of Birth/Fecha de nacimiento:

Ethnicity/origen étnico:

Thank you for your time! We will be contacting you soon.
¡Gracias por su tiempo! Alguien se comunicara con usted lo más pronto posible.

READ with Monterey County Free Libraries
188 Seaside Circle
Marina, CA 93933
831-883-7597

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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