APDC Student Registration Form
To register for class, please complete all the information below.
Gender *
Required
Birth Date *
MM
/
DD
/
YYYY
First Name *
Middle Name
Last Name *
Cell Phone Number *
Home Phone Number
Email Address
Street Address *
Apartment Number
City *
State *
Zip Code *
Country of Origin *
First Language *
Race / Ethnicity *
Required
Highest Level of Education *
Required
School completed in: *
Required
Work Status *
Required
Other Information
What are your goals?
How did you hear about us?
Did you come to the U.S. as a refugee? *
Required
If you came to the U.S. as a refugee, when did you arrive in the U.S.?
MM
/
DD
/
YYYY
If you came to the U.S. as a refugee, what was your resettlement agency?
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