Clone of Registration Form

Fall 2026 Semester

General Information

24 English Classes

48 Hours of Instruction

Location:

Mid-South Christian College

3097 Knight Rd, Memphis, TN 38118

Classes start: Sept 1 & 5 Classes End: Dec 4, 5

Registration

July 11 - Sept 1

Class Schedule Options

Tues & Fri | 6:00-8:00 PM

Sat | 10:00 AM-2:00 PM

Costs

New Students: $125

Returning Students: $110

Price includes Student Textbook

Payment Methods

Online during registration

In-Person - Cash, Card, Check

New students Must complete an English Level Assessment

in-person before beginning classes.

In-Person

Registrations, payments, and assessments may be completed at

Mid-South Christian College on:

Fri, Aug 28 | 6:00 PM - 8:00 PM

Sat, Aug 29 | 10:00 AM - 12:00 PM

Still have questions?

Text/whatsapp: 662-408-0295

Email: conexionmidsouth@gmail.com

Registration Form
Student Information

Privacy Notice: We will use your information only for Conexión Mid-South. We will not sell or share your information. Your information is only used to help us apply for funding and understand how our program is helping people.
What is your full name?

First Name Middle NameLast Name (s)Suffix
What name do you prefer?
Gender
Birthdate

DayMonthYear
2 digit day, 2 digit month, 4 digit yearBirthdate
Email

Confirmation Emailexample@example.com
Phone Number
Please enter a valid phone number.Format: 0000000000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: 0000000000.

Student Information (cont. )

Privacy Notice: We will use your information only for Conexión Mid-South. We will not sell or share your information. Your information is only used to help us apply for funding and understand how our program is helping people.
What country were you born in?
Home Country
When did you come to United States? If you were born here, you can put your birthdate.

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
What level of education did you complete?
What motivates you to study English?

Class Schedule Selection
Which class schedule would you like?
Are you a returning student?

Program Policies

Students must comply with the rules and guidelines outlined below
Mid-South Christian College Campus Policies
1. Tobacco, Drug, and Alcohol-Free Property: Mid-South Christian College is a tobacco, drug, and alcohol-free campus.
2. Weapons Policy: No weapons, ammunition, or explosives are permitted on the premises at any time.
3. Respect for Property: Students are expected to take care of books, supplies, and any materials provided by the program.
4. Use of Technology: Use any technology provided by the program responsibly and return borrowed items in good condition.
5. Prohibited Behavior: Harassment, bullying, and inappropriate language/gestures are not permitted.
Classroom Attendance and Behavior Policy
1. Adults Only: Students must be 18 years of age or older before classes begin.
2. Regular Attendance: Students are expected to attend all scheduled classes.
3. Punctuality: Arrive on time to each class. Tardiness disrupts the learning environment.
4. Notifying Absences: Notify the instructor or program coordinator in advance if you are unable to attend a class.
5. Respect for Others: Treat classmates and instructors with respect, regardless of cultural or language differences.
6. Participation: Actively participate in class activities and practice speaking, listening, reading, and writing.
7. No Disruptions: Refrain from using cell phones or other devices during class unless instructed otherwise.
Refund Policy

There are no standard refunds for courses.
Refunds may be issued within the first two weeks of classes only in the following situations:
- Required level not offered that semester after placement testing
- Relocation due to a major employment change or other situation beyond student's control.
- Illness or medical emergency preventing class attendance.
- Other extenuating circumstances approved by Conexion.
All refund requests are subject to the approval of Conexion Mid-South.
Consent for Photographs

Conexion Mid-South has permission to use my photos, images, and words to help promote the program.
I have read and agree to the policies outlined above.
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate

Payment Method
Current Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Final Price
Your tuition is for this semester is $ {typeA27}.
Please select your payment method.
Payments may be made at:

Mid-South Christian College

3097 Knight Road Memphis, TN 38118

on:

Fri, Aug 28 | 6:00 PM - 8:00 PM

Sat, Aug 29 | 10:00 - 12:00 AM

Payments are due by the first day of class.

Course Amount:

USDDescription

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Payment Status
Should be Empty:

Fall 2026 Semester

Registration Form

Student Information

Student Information (cont. )

Class Schedule Selection

Program Policies

Payment Method

Course Amount:*

Course Amount: