REGISTRATION FORM Waltham Beginner English Classes October 2018 - April 2019 at Brandeis University

This class is FREE. All students MUST register.

Beginner English Classes in Waltham
on Brandeis University campus

Classes meet TWO DAYS per week

**** We will notify you by phone or email of the class DAYS, TIMES and LOCATION *****

STUDENT INFORMATION
First Name
*
Your answer
Last Name *
Your answer
Gender *
Date of Birth *
MM/DD/YYYY
MM
/
DD
/
YYYY
Street Address *
Your answer
Apartment
Your answer
City *
Your answer
Zip Code *
Your answer
Phone number *
Your answer
Email
Your answer
re-enter Email
Your answer
How did you hear about the Beginner English Class?
Do you have an interpreter? *
Interpreter Name
Your answer
Interpreter phone number
Your answer
Interpreter email
Your answer
Emergency Contact Name *
Your answer
Emergency Contact relationship to you *
Your answer
Emergency Contact phone number *
Your answer
What country are you from? *
Your answer
What is your first language? *
Your answer
Race *
How much education do you have? *
Do you have a job right now? *
What is your yearly household income?
Do you identify as having low income?
PERMISSIONS
English At Large has my permission to use my photographic or electronic image in English At Large newsletters, publications, or press releases and on the Web. *
English At Large has my permission to publish my written or spoken words in English At Large newsletters, publications, or press releases, and on the Web. *
English At Large has my permission to publish my name on its donor list, should I choose to make a donation. *
English At Large has my permission to share my name, address, phone number, and email address with other members of English At Large. *
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