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? *

Yes No
What is the best way to contact you? *

Text Call Email
Birthdate *

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

Yes No
What is your race or ethnicity? (Check all that apply.) *

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
How many years did you go to school? *
Do you have a high school diploma? *

Yes No
If yes, what is the name of your high school?
Do you have a university or college degree or specialized training certificate? *

Yes No
If yes, what is the name of the school?
Are you currently enrolled in or attending a different school (high school or other)? *

Yes No
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) *

Yes No
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 barriers Disabled Displaced homemaker Low income Ex-offender Exhausting TANF within 2 years Homeless Long term unemployed Migrant farm worker Seasonal farm worker Single parent or guardian None
Are you currently working with any of the following Employment Security programs? (Check all that apply)

Wagner-Peyser Trade Adjustment Assistance Jobs for Veterans Unemployment Insurance TANF/NHEP
Are you currently working with any of the following Office of Workforce Opportunity programs?

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

Voc Rehab Career 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 college Get a better job Complete a training program Do an apprenticeship Be an active member of the community
What industry are you interested in?
Which of the following would you be interested in learning more about?

Apprenticeships Career opportunities Training opportunities Colleges Vocational 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? *

Yes No
When do you want to attend class? *

Morning Evening
How do you want to attend class? *

In-person Online
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*
Do you have access to any of the following technology to use for class? (Check all that apply.) *

Computer Tablet Smartphone None
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
Status
Class Placement
Staff Notes
Should be Empty:

Nashua ALC Registration Form - ESL (2022-2023)