HIC English Program Enrollment Form US Resident Only
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First Name *
Family Name *
Date of Birth *
MM
/
DD
/
YYYY
Address (Street) *
Zip *
County *
Telephone Number *
Email *
Gender *
Race *
Are you Hispanic or Latino? *
Country of Origin *
Primary Language *
Employment Status *
Your Status (check all that apply) *
Required
Highest Level of Education Completed *
Have you taken an online class before? *
(Select all that apply) I have access to a: *
Required
Agency Referral *
Required
Program of Interest *
Required
I can attend class in the morning on these days: *
Required
I can attend class in the afternoon on these days: *
Required
I can attend class in the evening on these days: *
Required
Do you prefer to participate in person? *
What is your goal (check all that apply)? *
Required
My annual income is: *
Have you received the COVID-19 vaccination? *
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