FLR Referral
Form
Form
Family Literacy of Racine
Referral Form
Thank you for referring this family to the FLR. Participants must meet all of the following criteria:
• Have an adult with a literacy need—learning English (ESL), learning to read, acquiring a GED/ HSED (ABE)
• Have at least one child from birth to 14 years of age
• Be able to attend class 5:30-7:30 pm Monday & Thursday
• Be 18 years of age
Please help us serve these families by providing the following information:
Adult: Name(s): ________________________________________________________
Address: _________________________________________________________
Phone number: ____________________________________________________
Children: Name: ______________ Birthdate: __________ School: _______________
Name: _____________ Birthdate: __________ School: _______________
Name: ______________ Birthdate: __________ School: _______________
Name: ______________ Birthdate: __________ School: _______________
*****All families must provide their own transportation*****
Your name/agency: _______________________________________________________
Phone number: ___________________ Date of Referral: _________________________
Send to: Richard Marciniak Phone: 898-3968
1925 Summit Ave Fax: 634-0835
Racine, WI 53404 richard@racinefamilyliteracy.com
________________________________________________________________________________________
For Office Use Only
Home Visit Scheduled No Contact Date Entering Program
Referral Form
Thank you for referring this family to the FLR. Participants must meet all of the following criteria:
• Have an adult with a literacy need—learning English (ESL), learning to read, acquiring a GED/ HSED (ABE)
• Have at least one child from birth to 14 years of age
• Be able to attend class 5:30-7:30 pm Monday & Thursday
• Be 18 years of age
Please help us serve these families by providing the following information:
Adult: Name(s): ________________________________________________________
Address: _________________________________________________________
Phone number: ____________________________________________________
Children: Name: ______________ Birthdate: __________ School: _______________
Name: _____________ Birthdate: __________ School: _______________
Name: ______________ Birthdate: __________ School: _______________
Name: ______________ Birthdate: __________ School: _______________
*****All families must provide their own transportation*****
Your name/agency: _______________________________________________________
Phone number: ___________________ Date of Referral: _________________________
Send to: Richard Marciniak Phone: 898-3968
1925 Summit Ave Fax: 634-0835
Racine, WI 53404 richard@racinefamilyliteracy.com
________________________________________________________________________________________
For Office Use Only
Home Visit Scheduled No Contact Date Entering Program
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