ESL Class Intake Form

Complete this form to determine eligibility for Human Migration Institute’s Riverside County Refugee and Ethnic Community Self-Help (RCRECSH) Community ESL Program, funded by the Office of Refugee Resettlement, an office of the he Administration for Children & Families under the U.S. Department of Health and Human Service. 

Human Migration Institute follows the California Privacy Right Act (CPRA) to protect against any loss and unlawful acts of selling and releasing private information outside of data collection and grant reporting purposes.

All services are free to eligible program participants.

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Name of Person Filling Out This Form

Prospective Participant (Primary Adult #1) – Write full legal name in this format: “LAST, First”

DOB
MM
/
DD
/
YYYY
Age

Location of Birth (City / District / Province / State / Country)

USCIS Alien Number

I-94 Number

Passport/National ID Number

Location of Most Recent Arrival in U.S. (Port of Entry)

Date of Arrival

MM
/
DD
/
YYYY
In relation to Date of Arrival

Legal status on the date of most recent arrival in the United States for Participant #1 (check one below):

CURRENT LEGAL STATUS

EDUCATION RECEIVED TO DATE (list most recent first)

Formal Name & Type of Institution, Location of Institution, Trs/Dates Attended
EMPLOYMENT HISTORY (list most recent first)

Formal Name & Type of Institution, Location of Institution, Trs/Dates Attended
Mobile Phone Number
E-mail Address
Select your status
Street Address & Apt #
City
State
Zipcode
Type of Household: Where do you live in?
Do you or your spouse own your household?
Household Size: How many total people live (or sleep overnight) in the home?
Clear selection
Household Composition: Does the previous number include only you and your immediate family, or does more than one family live together?
Other Members: List in order of age (oldest to youngest) the identity and relationship of each person in your immediate family

Please List: Full Legal Name, Gender, A#, I-94#, Age, DOB, and Relationship (Spouse, Unmarried Child/Youth age 0-24, or Other) 
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