Student Registration Form

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Book Fees is $20. After you submit the form, we will contact you for an assessment test appointment.

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Email *

Class Selection *

ESL In-Person CLASS FULL. Registration closed.

Citizenship - Wednesday 9-10 am (In-Person Class)

Learning Upgrade ESL Phone App (Self-paced Remote Learning)

Learning Upgrade GED-Math Phone App (Self-paced Remote Learning)

Learning Upgrade Phone App-Finance/Work Life Skills/Citizenship (Self-paced Remote Learning)

Required

Untitled Title

Student Information *

New Student

Returning Student

Previous ESL Class Level

First Name *

Last Name *

Gender *

Male

Female

Other:

Date of Birth *

YYYY

Age *

Address *

City *

State *

County *

Fort Bend

Harris

Brazoria

Other:

Zip *

Cell phone # *

Marital Status *

Married

Single

Divorced

Widow

Are you a US Citizen? *

Yes

Native Language *

What country are you originally from? *

Profession or job in your native country *

English Proficiency *

Fluent

Functional

Minimal

Ethnicity and Race *

Hispanic or Latino

Non Hispanic or Latino

White

Black

Asian

Other:

Required

Education *

Less than grade 12

High School Diploma

Some College

College Degree or above

Employment Status *

Full time

Part time

Retired

Unemployed

Emergency Contact Name *

Emergency Cell Phone # *

Emergency Contact Relationship to you *

How did you find out about the program? *

Friend or Family

Internet

Website

Other:

ASSUMPTION OF RISK, VOLUNTARY RELEASE, AND INDEMNITY AGREEMENT

In consideration of my participation in the program and any other activities in Fort Bend Care Center including any activities conducted during early arrivals and extended departures (Collectively, the “Activities”), I agree to assume any and all risks in injury or death arising from/or relating to the Activities and waive and release any and all actions, claims, suits or demands of any kind against Fort Bend Care Center (Care Center), Fort Bend Community Church (the Church) , their affiliates, officers, governing council, staff, agents, sponsors, volunteers or representatives of any kind arising from /or relating in any way to my voluntary participation in the Activities.

I agree to indemnify Care Center, the Church, their affiliates, officers, governing council, staff, agents, sponsors, volunteers or representatives of any kind in the event of any loss, damage or claim arising from /or relating in any way to my voluntary participation in any of the Activities whether caused by the negligence of Care Center, the Church or otherwise.

I hereby consent to and authorize Care Center to use and reproduce any photographs and/or video taken of me as needed in printed, web media and public material.

Do you agree to the above statement? *

Yes

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