Winter Term 2025 Registration Form

Winter Term 2025 Registration Form

Haga clic en la bandera estadounidense en la esquina superior para ver el formulario en español.
How old are you?*
Where do you want to take classes?

Milford Public LibraryBeebe HospitalLutheran Church of Our SaviorMilford Avenue Methodist Church
When do you want to take classes?

Lutheran Church of Our Savior 9:00 to 11:00 am Tuesdays and ThursdaysLutheran Church of Our Savior 6:30 to 8:30 pm Tuesdays and ThursdaysMilford Library 5:30 pm to 7:00 pm Tuesdays and ThursdaysBeebe Hospital 4:30 to 6:30 PM Tuesdays and ThursdaysMilford Avenue Methodist Church 6:00 to 8:00 pm Tuesdays and Thursdays
Are you a returning student?*

YesNo
Are you employed?

YesNo
If you are employed, what is your job?
What Level do you want?*

Basic Level - BeginnerLevel 1 - Advanced BeginnerLevel 2 - IntermediateLevel 3 - Advanced IntermediateLevel 4- AdvancedLevel 5- Transition
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.
Emergency contact name*

First NameLast Name
Emergency contact email*
example@example.com
Phone number of your emergency contact*
Please enter a valid phone number
How is your emergency contact related to you?*
Example: husband, mother
What is your gender*

FemaleMale
What method of communication do you want your teacher to use to communicate with you? Choose ONE*

TextEmailTelephoneWhatsApp
In what country were you born?*
What is your race?*

American Indian or Alaska NativeAsianBlack or African-AmericanNative of Hawaii or other Pacific IslanderWhiteI prefer not to say
What is your native language?
What is your ethnicity?*

Hispanic or LatinoNot Hispanic or LatinoI prefer not to say
What level of education have you completed?*

Primary SchoolSecondary SchoolUniversityAdvanced DegreeNone of the above
How many years have you lived in the United States?*
How did you learn about this ESL Program? Choose one.*

FriendsFacebookTelevision or RadioChurchNewspaperPosterOther
What is your main target? Choose one.

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
The church sometimes uses photos of students in itsmarketing materials, such as on its Facebook page, its website, or in newspaperarticles. Do you give the church permission to use your photograph in thisway?*

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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