ESL Enrollment Form 2020-2021- Life Skills and Academic Classes
Please complete all questions on this form before you go to your testing appointment. Thank you for completing this form.
* Required
Email address
*
Your email
Last Name
*
Your answer
First Name
*
Your answer
Middle Initial
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Cell Phone
*
If you do not have a cell phone, please list the best phone number to contact you.
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Gender
*
Female (Woman)
Male (Man)
Marital Status
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Single
Married
Separated
Divorced
Widowed
What country are you from?
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Your answer
Language
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Your answer
What is your highest level of education?
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Choose
I did not go to school.
1
2
3
4
5
6
7
8
9
10
11
12
High School Diploma
High School Equivalent (i.e. GED, HiSET)
Some College (no degree)
Associate Degree
Bachelor's Degree
Graduate or Professional Degree (i.e. Master's or Doctoral)
Unknown
In what year did you finish school?
*
For example- 1990, 2002, 2015. If you did not go to school, write NA.
Your answer
Where did you finish your degree?
In the United States
In my home country
Where do you live? See the picture for an example.
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Urban
Rural
Hispanic Origin
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A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race
Yes
No
How did you hear about us?
Choose
I am a returning student
Friend or Family
Facebook / Instagram
Twitter
Online Ad
Online Search
Outdoor signage (yard sign, billboard, etc.)
Print Advertising (newspaper, magazine, etc)
Radio
TV
Community Agency (Dismas, Healing Place, Corrections, etc.)
Other
Data Matching Consent
*
I give the Kentucky Education and Workforce Development Cabinet and KYSU [Office of Adult Education (OAE)] permission to release my post-secondary enrollment, GED Testing Service® information, and employment status to KYSU providers as well as this enrollment information to the Kentucky Council on Postsecondary Education, the Kentucky Community and Technical College System or any other public postsecondary institution.
Yes
No
Race
*
Select all that apply. US Census Definitions: White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa | Black or African American – A person having origins in any of the Black racial groups of Africa | American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America) | Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent | Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
American Indian / Alaskan Native
Black or African American
Asian
Hispanic or Latino
White, not of Hispanic origin
Native Hawaiian or Pacific Islander
Required
Are you currently receiving:
Unemployment Insurance
Disability SSI
Temporary Assistance for Needy Families (TANF)
SNAP benefits ("Food Stamps")
Medicaid
Other Information
*
Immigrant
Refugee
US Citizen
Visa- Write Visa type below in Other.
Veteran
Homeless
Required
Are you working? Do you have a job?
Yes, I am working. I have a job. (EMPLOYED)
No, I do not have a job. BUT I am looking for a job. (UNEMPLOYED)
No, I do not have a job. I do not want a job right now. (NOT IN THE LABOR FORCE)
Clear selection
How many children do you have in the U.S. (baby to 18 years old)?
Your answer
How old is each child (baby to 18 years old)?
Your answer
Do you want online English class in the morning or evening?
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Morning
Evening
Did you attend English classes with us before?
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No, I am a new student.
Yes, at Bethlehem Baptist Church (LAESL).
Yes, at Americana World Community Center.
Yes, at Ahrens Learning Center.
Yes, at Jeffersontown High School.
Yes at McFerran Elementary School.
Yes, at Seneca High School.
Yes, I took online Zoom classes in April and May 2020.
When we return to school, how will you go to class?
*
Drive my car
Ride with a family or friend
Walk
Ride the bus
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