Orange Literacy Student Registration
Registration Form
Email *
What type of class are you most interested in? (choose one) *
What is your first name? *
What is your last name? *
What is your phone number? *
What type of phone number is this? *
What is your email address (if any)?
What is your street address?
What city do you live in?
What North Carolina county do you live in?
What is your zip code? *
What is your birthdate? *
MM
/
DD
/
YYYY
What is your gender? *
What is your race? (check as many as apply) *
Required
Are you Hispanic/Latinx? *
What is your highest level of education? *
In what country did you last attend school? *
What is your employment status? *
What is your average household monthly income?
For any children living in your household, how many are age 0-6?
For any children living in your household, how many are age 7-18?
Please provide an Emergency Contact name:
Please provide an Emergency Contact phone number:
When are you able to attend class? *
Required
Which days are best for you? (choose at least two) *
Required
Where can you meet? *
Required
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