Nashua ALC Registration Form

Nashua ALC Registration Form - ESL (2022-2023)

Please complete all information and click SUBMIT at the bottom of the page. A staff member will contact you within a few weeks after you submit the form to complete the registration process. Students are required to live or work in New Hampshire to qualify for class. If you have questions or need assistance completing this form, contact the Adult Education Counselor (Samba) at 603-689-3539 or email shalkose@nashuaalc.org.
Name*

First Name Last Name
Address*

Street Address

Street Address Line 2

City State

Zip Code
Email*
example@example.com
Phone Number*

Area Code Phone Number
Can we text you at this number?*

YesNo
What is the best way to contact you?*

TextCallEmail
Birthdate*

MonthDay Year
Date
Gender*
What country were you born in?
What is your first language?
Are you Hispanic or Latino?*

YesNo
What is your race or ethnicity? (Check all that apply.)*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
How many years did you go to school?*
Do you have a high school diploma?*

YesNo
If yes, what is the name of your high school?
Do you have a university or college degree or specialized training certificate?*

YesNo
If yes, what is the name of the school?
Are you currently enrolled in or attending a different school (high school or other)?*

YesNo
If yes, what is the name of the school?
Are you currently employed? (Please note, if you work in the US as an Au Pair, you are not eligible to participate in our program)*

YesNo
Are you looking for work?*

Yes, I am looking for work.No, I am not looking for work.No, I am retired.
If you are working, what is the name of the company or industry?
How many hours (about) do you work per week?
Do you have any barriers to employment? (Check all that apply.)*

Cultural barriersDisabledDisplaced homemakerLow incomeEx-offenderExhausting TANF within 2 yearsHomelessLong term unemployedMigrant farm workerSeasonal farm workerSingle parent or guardianNone
Are you currently working with any of the following Employment Security programs? (Check all that apply)

Wagner-PeyserTrade Adjustment AssistanceJobs for VeteransUnemployment InsuranceTANF/NHEP
Are you currently working with any of the following Office of Workforce Opportunity programs?

WIOA AdultWIOA Youth/NH JAG/My TurnDislocated Worker (Title I)SCSEP/National Able
Are you currently working with any of the following Department of Education programs?

Voc RehabCareer and Tech. Ed.Adult Education other than this center - please type name of program below:
The Adult Education Counselor will help you overcome barriers to attending class and work towards your goals. Let us know below what types of things you are interested in learning more about.
What is your main goal after learning English?

Go to collegeGet a better jobComplete a training programDo an apprenticeshipBe an active member of the community
What industry are you interested in?
Which of the following would you be interested in learning more about?

ApprenticeshipsCareer opportunitiesTraining opportunitiesCollegesVocational workshops
What challenges could get in the way of you achieving your goals? (We ask this so we can help you overcome them.)
The Nashua Adult Learning Center reserves the right to ask students to leave the classroom if we observe Covid related symptoms such as: coughing, sneezing or fever. If you test positive for Covid, please follow all recommended CDC guidelines before returning to class.
Have you taken class with the Adult Learning Center before?*

YesNo
When do you want to attend class?*

MorningEvening
How do you want to attend class?*

In-personOnline
Please note: for online classes, having your camera turned on during the class session is required. If you have special circumstances that prevent you from having your camera on, please let us know.

Examples include: medical issues, learning difficulties, classroom comfort needs

*This information will be treated as confidential*

Attendance policy: after 3 unexcused absences you will be removed from class and be asked to attend the next open session.
Do you have access to any of the following technology to use for class? (Check all that apply.)*

ComputerTabletSmartphoneNone
How comfortable do you feel using technology?*
Is there anyone (parent, child, case worker, etc.) you give us permission to talk to about your education? (If yes, please list.)
Is there anything else we should know about you? (For example: medical issues, learning difficulties, classroom comfort needs, etc.) This question is optional.
Privacy Policy and Statement of Confidentiality

I understand that my information will be treated as confidential and used only for educational purposes. It will be seen only by education staff members who are required to treat all student information as private. If you agree, please sign below using your mouse or finger.
Signature*

Clear
Release of Information Form

Please read through the NH Works System Partners Release of Information form. If you agree, please sign below using your mouse or finger.
I have read the release of information form and agree to share information with NHWORKS partners.
Signature

Clear
Status
Class Placement
Staff Notes
Should be Empty:

Nashua ALC Registration Form - ESL (2022-2023)