Learning Lab Interest Form
CURRENT WAIT TIME FOR CLASSES IS ESTIMATED BETWEEN 4-8 MONTHS. 
OUR WAITLIST IS NEEDS-BASED (INCOME AND ENGLISH LANGUAGE LEVEL)
If you need help completing this form or have any questions, please email tracyc@learninglabinc.org

NOTE: You must be 18 years or older to take our Adult Education classes. 

All information given is confidential and is not shared with other organizations or agencies.
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Untitled Title
What is your name?  *
What is your gender?
Clear selection
What is your phone number? (example: 123-456-7890) *
What is your email?
Do you have children between 3 months-old to 5 years-old that you would like to bring to Family Literacy class?
Clear selection
If you have children you would like to bring, what are their names and birthdays?
What would you like to work on in class?
Clear selection
When would you like class?
(Family Class is only mornings and afternoons)
Clear selection
Where would you prefer to have class? 
(Family Literacy is only at the Garden City location)
Clear selection
Do you have transportation?
Clear selection
What is your English level?
Clear selection
How many people live in your house? *
How much money does your household make in a month? *
What is your birthday?
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What is your Street Address and Zip Code? (example: 308 E 36th St.  83714)
What is the name of your emergency contact?
What is the phone number of your emergency contact? (example: 123-456-7890)
Why do you want to be in class?
Clear selection
What country are you from?
What's your preferred language?
When did you come to the United States?
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/
DD
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What is your race?
Clear selection
What is the last grade you completed in school?
Clear selection
Did you attend school in the United States?
Clear selection
What is your employment status?
Clear selection
Have you ever been convicted of a violent crime in the United States? *
How did you hear about Learning Lab?
Clear selection
Is there anything else we should know about you?
As a student, you agree to:
- Come to the class you are enrolled in
- Be on time for class
- Stay the entire class
- To call/text the teacher before class if you cannot come to class
 *
Student's name and photos may be used for TV, newspapers, Learning Lab's website, social media (Facebook, Twitter, Instagram), email, and newsletters. Learning Lab can use my: *
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