ESL Enrollment Form 2020-2021- Life Skills and Academic Classes
NOTE: We are not longer using this enrollment form due school year 2020-2021 is finished.
Please text or email your full name, phone number, email and zip code to Laura Jimenez for an appointment to register in-person.
Laura Jimenez: (502)953-0930  laura.jimeneztlalpachicatl@jefferson.kyschools.us

Please complete all questions on this form before you go to your testing appointment. Thank you for completing this form.
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Email *
Last Name *
First Name *
Middle Initial
Date of Birth *
MM
/
DD
/
YYYY
Cell Phone *
If you do not have a cell phone, please list the best phone number to contact you.
Address *
City *
State *
Zip Code *
Gender *
Marital Status *
What country are you from? *
Language *
What is your highest level of education? *
In what year did you finish school? *
For example- 1990, 2002, 2015. If you did not go to school, write NA.
Where did you  finish your degree?
Where do you live? See the picture for an example. *
Captionless Image
Hispanic Origin *
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race
How did you hear about us? *
Data Matching Consent *
I give the Kentucky Education and Workforce Development Cabinet and KYSU [Office of Adult Education (OAE)] permission to release my post-secondary enrollment, GED Testing Service® information, and employment status to KYSU providers as well as this enrollment information to the Kentucky Council on Postsecondary Education, the Kentucky Community and Technical College System or any other public postsecondary institution.
Race *
Select all that apply. US Census Definitions: White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa | Black or African American – A person having origins in any of the Black racial groups of Africa | American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America) | Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent | Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Required
Are you currently receiving:
Other Information *
Required
Are you working? Do you have a job? *
How many children do you have in the U.S. (baby to 18 years old)?
How old is each child (baby to 18 years old)?
Do you want online English class in the morning or evening? *
Did you attend English classes with us before? *
When we return to school, how will you go to class? *
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