2022-2023 Student Registration Form

2022-23 ESL Registration Form

Haga clic en la bandera estadounidense en la esquina superior para ver el formulario en español.
How old are you?*
YesNo
Lutheran Church of Our SaviorMilford Public Library (Basic Level OnlyBeebe Hospital
YesNo
9:00 - 11:00 am Tuesday and Thursday6:30 - 8:30 pm Tuesday and Thursday5:30 - 7:00 pm Tuesday and Thursday in the Milford Library
YesNo
If you are employed, what is your job?
Basic Level - BeginnerLevel 1 - Advanced BeginnerLevel 2 - IntermediateLevel 3 - Advanced IntermediateLevel 4 - Advanced
Name*

First NameLast Name
Home Address*

Street Address

Apartment Number OR P. O. Box

CityState

Postal Code
Email:*
example@example.com
Mobile Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency contact name*

First NameLast Name
Emergency contact email*
example@example.com
Phone number of your emergency contact*
Please enter a valid phone numberFormat: (000) 000-0000.
How is your emergency contact related to you?*
Example: husband, mother
FemaleMaleOther
TextEmailTelephoneWhatsApp
In what country were you born?*
American Indian or Alaska NativeAsianBlack or African-AmericanNative of Hawaii or other Pacific IslanderWhiteI prefer not to say
What is your native language?
Hispanic or LatinoNot Hispanic or LatinoI prefer not to say
Primary SchoolSecondary SchoolUniversityAdvanced DegreeNone of the above
How many years have you lived in the United States?*
FriendsFacebookTelevision or RadioChurchNewspaperPosterOther
Learn to speak or improve my EnglishLearn to read and write in EnglishFind a jobEnroll in college or continue my educationAttend a Parent-Teacher ConferenceObtain a driver's licenseGet a job promotionOther
YesNo
Delaware residents who are at least 18 years of age are eligible for this program. We hope that you will be able to find a suitable English program close to home. We wish you the best of luck.
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2022-23 ESL Registration Form