VOCES Spring 2020 ESL Registration Form

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Last Name

First Name(s)

Gender

Female

Male

Prefer not to say

Clear selection

Address

City

State & Zip code

Date of Birth

YYYY

Home Phone Number

Cell Phone Number

Email address

Place of Birth (City and State/Country)

Primary Language:

Spanish

Portuguese

Burmese

Falam

Hakha

Tedim

Japanese

Russian

Other

Clear selection

If you checked "Other" what is your primary language?

Are you Hispanic?

Yes

Clear selection

Ethnicity/Nationality

Mexican

Puerto Rico

Cuban

Dominican Republic

Burmese

Japanese

Central American*

South American*

Multi-ethnic*

Other*

Clear selection

*If you checked South American, Central American, Multi-ethnic or other, please type your answer below.

Racial Group (Select one or more that apply)

Black or African American

Native American or Alaskan Native

Asian

Native Hawaiian or Other Pacific Islander

White

Marital Status

Single

Married

Domestic Partnership

Seperated

Divorced

Widowed

Clear selection

What is your highest level of education?

No schooling

Grades 1-5

Grades 6-8

Grades 9-12 (No diploma)

High School Diploma/alternative credential

GED

Some college, no degree

College or professional degree

Clear selection

Was your schooling completed in the USA?

Yes

Clear selection

Household Annual Income:

Less than $10,000

$10,000 - $19,999

$20,000 - $29,999

$30,000 - $39,999

$40,000 - $49,999

More than $50,000

Clear selection

Years of living in the United States

Job Status:

Employed

Unemployed, seeking employment

Unemployed, NOT seeking employment

Clear selection

If employed, where?

Are you: (check all that apply)

Receiving Public Assistance (e.g. Medicaid, Food Stamps)

Disability

Displaced Homemaker

Learning Disability

Living in a Rural Area

Dislocated Worker

Low Income

None of the above

Please list names of people living in your household and their D.O.B. For example, Jane Doe 01/01/01

Do you need child watch during the class? *

Yes

If your answer is YES, please provide the child/ren's name(s) and the dates of birth.

Do you need ride service during the class in Spring session? *

Yes

Emergency contact person's name:

Emergency contact phone number:

I understand all information I provided to Voces/YMCA is confidential and is shared with funding partners as required. I give permission for Voces/YMCA to take and use my and/or my family's pictures and/or video in any Voces/YMCA promotional materials. I understand that if I do not wish to have pictures taken or used by Voces/YMCA. I must notify the Voces' Director in writing. I also agree to abide by all Voces' policies and procedures, including but not limited to, Child Care policies, building policies and Code of Conduct. I agree to hold Voces harmless from any liability in connection with the loss of life, personal injury and/or damage of property arising from my participation in classes and/or my children's participation in child care.

Check the box indicates that you have read and agreed the statement above.

Student Signature: (Type your full name) *

Date:

YYYY

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