Adult Education Registration Form

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Junta’s online Continued Education courses are designed to improve participants' communication skills for social and career development opportunities by advancing their academic qualifications and English language skills.

Junta partners with several New Haven organizations to offer Continuing Education courses to our participants; General Education Development (GED) and English as a Second Language (ESOL).

Email *

Nombre / Name *

Nombre y Apellido / First and Last Name

Número de Teléfono / Phone Number *

Dirección / Address *

Fecha de Nacimiento / Date of Birth *

YYYY

Género / Gender *

Male

Female

Gender Non-Conforming / Non-Binary

Other:

País de Nacimiento / Country of Birth *

Etnia / Ethnicity *

Hispano/a/x o Latino/a/x / Hispanic or Latino

NO Hispano/a/x o Latino/a/x / NPHispanic or Latino

¿Cuántos hijos tiene (si es que tiene alguno)? / How many children do you have (if any)? *

Si respondió la pregunta anterior, incluya las edades de cada niño (o "N/A" ) / If you answered the previous question, please include the ages of each child (or "N/A" ) *

Nombre de Contacto de Emergencia / Emergency Contact Name *

Contacto de Emergencia Telefono / Emergency Contact Phone *

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