Adult Literacy Program Intake Assessment

Adult Literacy Program Intake Assessment — Form Fields

This education template includes 12 fields. Intake assessment form for adults enrolling in literacy and basic education programs. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Email (email, optional)
• Phone Number (text, required)
• Date of Birth (text, required)
• Highest Education Completed (dropdown selection, required) — options: No Formal Education, Some Elementary, Completed Elementary, Some High School, GED, Some College
• Primary Language (dropdown selection, required) — options: English, Spanish, Mandarin, Arabic, Vietnamese, Somali, Other
• English Proficiency (dropdown selection, required) — options: Beginner, Intermediate, Advanced, Native Speaker
• Program Interest (dropdown selection, required) — options: Basic Reading and Writing, GED Preparation, ESL (English as Second Language), Digital Literacy, Workforce Readiness
• Availability (dropdown selection, required) — options: Morning (9am-12pm), Afternoon (1pm-4pm), Evening (6pm-9pm), Saturday
• Need Transportation Assistance (multiple choice, required) — options: Yes, No
• Need Childcare During Classes (multiple choice, required) — options: Yes, No
• Personal Learning Goals (long text, required)