Learn to Read Jacksonville

Mailing Address: P.O. Box 2178

Jacksonville, FL 32203
Office Address: Main Library 303 N. Laura St.
Jacksonville, FL 32202
Phone (904) 238-9000 Fax: (904) 630-7162
E-mail: buchholz@coj.net
Website: www.learntoreadjax.org

TUTOR REGISTRATION FORM

(Please print)
Name:

________________________________________________________________
Last

Address:

First

________________________________________________________________
Street

Apt. #

City/State:

__________________________________________ Zip: _________________

Phone:

________________________________________________________________
Home

Email:

Work

________________________________________________________________

Birth date:
_______________
(For database purposes only)

Ethnicity: _____________
(For database purposes only)

Gender: ____________
(For database purposes only)

How did you learn about us? ____________________________________________________

Workshop registering for (date): __________________________________________
Workshops may be cancelled due to low enrollment. In this event, you will be notified and presented
options to transfer registration to upcoming workshops.

*Fee must be received with workshop registration*

Please choose one of the following
______ Enclosed is my registration fee of $25. I will commit to tutor a LTR student.
______ Enclosed is my registration fee of $50. I will not be tutoring a LTR student.
Signature: _______________________________ Date: ____________________________
Please complete this form and return it with your check. Applicants will be registered in workshop
once they have submitted prerequisite online workshops certificates. Upon receipt, workshop
registration confirmation email will be sent and you will receive a reminder phone call one-week prior
to the workshop.

The World One Word At A Time

*Non-refundable Fee