Roseville Adult School ESL Online Class Enrollment For New Students for Fall
Please complete for fall enrollment of new students. Fall Classes begin the week of Aug 17th.
**Your teacher will contact your after filling out the form with class information.
Email address *
Are you in an Roseville Adult School English as a Second Language class now? *
Required
If so, who is your teacher?
What is your first name? *
What is your last name? *
Gender *
Date of Birth (month, day, year) *
MM
/
DD
/
YYYY
Email *
Phone ( xxx)-xxx-xxxx *
Street Address *
Zip Code, *
City, State *
Emergency Contact: (name and phone) *
Ethnicity *
Race (Mark all that apply) *
Required
Language Spoken *
Years of School *
Highest level of Education completed (Pick one) *
Where did you complete your education? *
Employment (Right now I am) *
Employment Barriers (Mark all that apply) *
Required
Special Programs (Mark all that apply) *
Required
What are your goals? (Pick Two) *
Required
I agree this information is true (type your name) *
Click blue submit button to complete form
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