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 (ELL), 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:  Donna Lyons                              Phone: 898-3968
1510 Villa Street                                          Spanish: 456-1779
Racine, WI 53403                             

For Office Use Only
Home Visit Scheduled                                       No Contact                                      Date Entering Program