BoulderReads! Inmate Intake and Report Form

Tutor Name

Inmate Name Age Gender

Ethnicity (check one):
Asian Hispanic White, not Hispanic Black Native American Mixed/Unknown

City/County of Residence US Citizen (y/n)

Native Country Native Language # of Children

Country of Education H.S. Diploma (y/n) GED (y/n)

Last grade of school completed Received special ed services (y/n)

Disability

Educational / occupational goals

Last job held

Approximate reading level

Dates tutored

What did you work on?

Student's Achievements