Application for MIPO, Inc. English Language Learner Class
Please complete all questions.
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Part I - General Info
First Name *
Last Name *
Cell Phone Number *
Month and Day of Birth, DO NOT INCLUDE YEAR. *
Country of Residence *
City in the Country of Residence *
Rate your proficiency in English
 *
Required
How did you hear about the class? *
Required
Do you have a laptop?
 *
Required
Which internet service do you have?
 *
Required
Do you have a gmail account?
 *
If you don't have a gmail account, you will need to create one by the time you join the class.
Required
If you answered yes to the last question, please type your gmail account below.
 *
Part II - Emergency Contact
Please write contact info (full name and phone number) of someone for us to get in contact with in case of an emergency.
First Name
 *
Last Name
 *
Phone Number
*
Email Address
 *
How are you related to that person?
 *
Part III - Additional Questions
What do you like to do in your spare time? *
Once accepted into the course, I give MIPO, Inc. permission to use my name and photo for the sole purpose of the program. *
Would you like to subscribe to our mailing list so that you can remain informed of our programs/events?
 *
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