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ESL PRE-REGISTRATION FORM
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First Name
*
Please enter your first name
Your answer
Last Name
*
Please enter your last name
Your answer
Phone Number
*
Please enter your 10-digit phone number
Your answer
E-Mail Address
*
Please enter your email address, if available
Your answer
Date of Birth
*
Please enter your birthday in MM/DD/YYYY format
Your answer
Program of Interest
*
Please check all that apply
High School Equivalency Diploma (HSED)
High School Diploma
Paraprofessional Certification
WIN Certification (formerly WorkKeys)
Enrichment
College and Military Entrance Exam Prep
ESL
Career Pathways Through Family Literacy/SC Continuing Ed Early Care and Education Professionals
Other:
Required
Permission Letter
*
Are you 17 years old? If YES, you must contact Lexington/Richland Five Office of Student Services at 803-476-8121 to request a permission letter.
Yes
No
Previous Locations
Have you previously attended an ESL Education Center? If so, which location.
ESL - Ashland Methodist Church Site
No Previous Location
Other
Other Comments or Questions
Please enter any questions or comments you have.
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