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Richland One Adult Ed ESL Class Registration
Please fill out all information in English. You can use a translator if needed.
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* Indicates required question
What is your LAST name?
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Your answer
What is your FIRST name?
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Your answer
What is your mailing address?
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Your answer
What city do you live in?
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Your answer
What is your zip code?
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Your answer
What COUNTY do you live in?
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Your answer
What is your home phone number?
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Your answer
What is your email address?
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Your answer
What is your birthday?
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MM
/
DD
/
YYYY
What is your age?
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Your answer
What is your gender?
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Male
Female
Are you Hispanic/Latino?
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Yes
No
What is your race?
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Black or African American
White
Asian
American Indian or Alaskan Native
Other:
What is your employment status?
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Employed full time
Employed part time
Unemployed and looking for work
Unemployed but not looking for work
What level of education have you completed?
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High school diploma or equivalency
Some university education (no degree)
University or professional degree
I did not finish high school
No Schooling
If you did not finish high school, what was the last grade you completed?
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Your answer
Did you go to school in the United States?
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Yes
No
Have you attended Adult Education before?
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Yes
No
If you attended Adult Education before, where and when (list the name of the program you attended and year you last attended)?
Your answer
If you are between 17-21 years old, are you CURRENTLY expelled from school?
Yes
No
Clear selection
If you are under 21, have you ever been served with special education services (for example, IEP or 504 plan?)
Yes
No
Clear selection
Do you receive Public Assistance?
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Yes
No
If you receive Public Assistance, what do you receive? (Examples: SNAP, TANF, WIOA, other...)
Your answer
Are you an immigrant?
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Yes
No
What country were you born in?
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Your answer
What is your native language?
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Your answer
Are you disabled?
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Yes
No
If you are disabled, what is your disability?
Your answer
Please list an emergency contact person (Name and phone number of someone we can call if you get sick or hurt in school).
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Your answer
Do you have a phone with Internet access? (We may need to do a placement test via Internet due to Covid-19.)
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Yes
No
Do you have access to the Internet and a computer or laptop at home with speakers, a microphone, and camera? (We may need to do a placement test via Internet due to Covid-19.)
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Yes
No
How do your rate your ability to speak English?
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poor
1
2
3
4
5
very good
How do you rate your ability to write English?
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poor
1
2
3
4
5
very good
How do your rate your English grammar skills?
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poor
1
2
3
4
5
very good
What class schedule do you prefer?
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Morning: Monday, Tuesday, Wednesday, Thursday from 8:30am - 11:30am
Evening: Tuesday and Thursday from 5:30pm - 8:30pm
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