Learner Registration Form

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The questions on this form help Indy Reads place students in programs. We also provide some information to funders about the types of students we serve each year. Your responses help us to track our impact and keep programs free. 

Our intake form is available in several other languages here: https://indyreads.org/registration-forms/. If you complete the form in a language other than English, Indy Reads will assess your English skills first to ensure that you are placed in a class that best meets your current literacy level.

Directions: If you want to complete the form in English, please complete all fields below.

Student Information

Date of Birth

Indy Reads serves adult learners in the state of Indiana. Please share your country, and if applicable, your state and city below. Your submission will be used as data to explore the possibility of expanding our programming in other regions. Thank you!

Education Level


Ex-Offender Status

Treatment/Rehab Status

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