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.
Date of Birth
If you do not have a cell phone, please list the best phone number to contact you.
What country are you from?
What is your highest level of education?
I did not go to school.
High School Diploma
High School Equivalent (i.e. GED, HiSET)
Some College (no degree)
Graduate or Professional Degree (i.e. Master's or Doctoral)
In what year did you finish school?
For example- 1990, 2002, 2015. If you did not go to school, write NA.
Where did you finish your degree?
In the United States
In my home country
Where do you live? See the picture for an example.
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race
How did you hear about us?
I am a returning student
Friend or Family
Facebook / Instagram
Outdoor signage (yard sign, billboard, etc.)
Print Advertising (newspaper, magazine, etc)
Community Agency (Dismas, Healing Place, Corrections, etc.)
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.
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
Hispanic or Latino
White, not of Hispanic origin
Native Hawaiian or Pacific Islander
Are you currently receiving:
Temporary Assistance for Needy Families (TANF)
SNAP benefits ("Food Stamps")
Visa- Write Visa type below in Other.
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)
How many children do you have in the U.S. (baby to 18 years old)?
How old is each child (baby to 18 years old)?
Do you want online English class in the morning or evening?
Did you attend English classes with us before?
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
Ride the bus
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This form was created inside of Jefferson County Public Schools.