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Student Intake Form
Student Intake Form for ESL/Civics/Citizenship Program
* Indicates required question
Email
*
Record my email address with my response
The Justice for Jenny Foundation ESL/Civics/Citizenship Education Program
Date
*
MM
/
DD
/
YYYY
Full Name
*
Your answer
Email Address (an email address is required for joining online classes)
*
Your answer
Address (not required but helpful for mailing learning materials)
Your answer
Contact Phone Number
*
Your answer
Student's country of birth
*
Your answer
Number of years living in the United States:
*
Your answer
Student is a
*
citizen
permanent resident
refugee
Other:
Required
Has student taken ESL classes before?
*
yes
no
Required
If yes, where?
Your answer
When?
Your answer
For how long?
Your answer
What level did the student get up to?
Your answer
Languages student speaks:
Your answer
Language spoken at home:
*
Your answer
Currently employed?
*
Yes
No
If yes, what is your current job? What type of work do you do?
Your answer
What type of work did you do in your native country?
Your answer
Student's class availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning (9:00 - 12:00)
Afternoon (1:00 - 4:00)
Evening (5:00 - 8:30)
Other notes:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning (9:00 - 12:00)
Afternoon (1:00 - 4:00)
Evening (5:00 - 8:30)
Other notes:
Submit
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