Fall Term 2025 Registration Form

How old are you?*
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.
What Level do you want?*

Basic Level - BeginnerLevel 2 - IntermediateLevel 3 - Advanced IntermediateLevel 4- AdvancedLevel 5- Transition
Where and 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 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 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 native language?
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 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? Check only 1.

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 its marketing materials, such as on its Facebook page, its website, or in newspaper articles. Do you give the church permission to use your photograph in this way?*

YesNo
Emergency contact name*

First NameLast Name
How is your emergency contact related to you?*
Example: husband, mother
Phone number of your emergency contact*
Please enter a valid phone number
Do you have any disabilities or require any accommodations to participate fully in this program?

YesNo
If yes, please describe the accommodation {s} you require.
Should be Empty: