ESL Registration Form - Literacy Alliance of NEFL

Which best describes you?

I am a new student

I am a returning student

Student Data

First Name

Last Name

Middle Name

Phone

May we text you?

Yes

Address 1

Address 2

City

State

5 Digit Zip Code

Demographics

Birthdate

Age must be 16 or older

9 Digit Social Security Number

If available, please upload a copy of your ID

Maximum file size: 65MB

Parent or Guardian Name

First

Last

Parent or Guardian Email

Parent or Guardian Phone

Sex

Male

Female

Preferred Pronouns

He/Him

She/Her

They/Them

Race

Are you Hispanic/Latino?

Yes

Are you a U.S. citizen?

Yes

Home Country

Native Language

Emergency Contact

Name

First

Last

Relation

Phone

Employment

Employment Status

Occupation

How many months have you been unemployed?

Barriers to Employment

I am or have been a youth in foster care

I am an ex-offender or have been involved with the justice system

I have been at home as a caretaker and now I’m unemployed

I or my parents are a migrant or seasonal farm worker

I am a single parent with custody of children

I am a single pregnant woman

I can’t find work because of my attitude, belief, custom or practice that influences the way I think, act, or work

Class Schedule

I am available for class on the following days:

I can attend class anytime / day

Yes

Monday

Tuesday

Wednesday

Thursday

Friday

Household

Marital Status

Married

Single

Divorced

Widowed

Do you receive public assistance? (TANF, SNAP, Section 8, EBT, etc)

Yes

If you receive TANF, will it end in the next 2 years?

Yes

Does not apply

How many people live in your house?

Household income per month

How many dependents do you have?

How old are your dependents?

Are you a homemaker?

Yes

If yes, what impact does homemaking have on you?

Taking care of my family has hurt my work skills and I have trouble getting hired

I am losing public assistance (TANF) and have trouble getting hired

My youngest child is turning 16 and I'm losing Social Security payments

My spouse is in the military and I need employment due to deployment, PCS, death or disability of the service member

None of these apply

Are you homeless?

Yes

If yes, what is your living situation like?

Living in a shelter or other transitional housing

Sleep in a specific place every night that is not housing

Under 18 and choose not to live at home

None of these apply

Education

Last grade completed in school:

Did you go to school in the United States?

Yes

Goals

What are your long term and short term goals?

Learn to speak English

Learn about citizenship

Learn about finances and money

Learn about technology

Learn about work and career opportunities

Meet new people

Earn a GED or Diploma

OtherOther

Social Services

Do you have a computer at home?

Yes

Do you have internet at home?

Yes

How did you hear about us?

Friend or Family

Online

Agency Referral

OtherOther

Do you use our partners?

YMCA

Beyond90

Clay County Public Library

Jacksonville Public Library

North Florida Sales

Islamic Center of Northeast Florida

Are there other services you need help accessing?

Do you have any health or medical conditions we should know about?

Agreements

Media Consent to Release

I give permission for Literacy Alliance to take and use photographs for program brochures, newsletters, or social media.

FERPA Agreement

I consent to the release of my education records including TABE, CASAS, and GED test scores to Literacy Alliance of Northeast Florida and its partner programs. This data will only be used for educational and school improvement purposes including required State and Federal reporting.  Further disclosure of personal data is prohibited and will not be shared with any partners. Declining to share your academic data will not impact eligibility to receive services.

Student Signature

Clear

Parent or Guardian Signature

Clear

Student Responsibilities Agreement

1. I will actively participate in educational activities and tasks. I must be engaged in instruction and respectful of fellow students' right to a positive and productive learning environment in order to stay in LANEFL’s program.
2. I agree to maintain appropriate behavior while in the LANEFL program; any disrespectful, disruptive, abusive or threatening acts or language will result in immediate termination from the program. 
3. Appropriate behavior is expected toward staff, fellow students, and any people present at the learning site, regardless of their involvement with LANEFL. Site premises are not for loitering or socializing.
4. I agree to complete assigned homework and practice lessons on a regular basis.
5. I understand that I am responsible for my own transportation.
6. I agree to attend regularly, be on time, and stay the entire scheduled class time.
7. I agree to call LANEFL in advance of any absence or if I expect to be late.  I understand that if I miss three classes without calling, I may be dismissed from the program. Arriving late or leaving class early will be counted as an absence.
8. Non-attendance for one month will result in withdrawal from the program. You will need to call the front office to re-apply.
9. I agree to inform the LANEFL office if any problems arise with my teacher, tutor, or class/lab by submitting an incident report.
10. I agree to notify LANEFL with any change of my contact information (email, address, or phone).
11. I agree not to bring children or other visitors with me to class, learning lab, or tutoring sessions.
12. I understand that I am responsible for the safekeeping of my own learning materials including workbooks and school supplies.
13. I will not use or be in possession of intoxicating substances while participating in LANEFL programs.
14. I will follow the rules of the building sites where LANEFL programs take place.

STUDENT RIGHTS
1. I have the right to a safe, positive and productive learning environment.
2.  I have access to LANEFL services including small group, learning lab, or individual learning options, as available. LANFEL programs are free of charge.
3. Bus passes may be available to students who have fully attended a learning session.
4. I have the right to submit an incident report with the office if I have any problems arise with my teacher, tutor, or class/lab. Assistance in filling out the form will be available if requested.
5. I understand that LANEFL can find resources or provide some accommodations for students with disabilities to comply with the Americans with Disabilities Act. However, assistance is limited to educational tools or assistive technology that helps students access lesson materials.  LANEFL cannot assist in activities of daily living, such as assistance with movement, preparing meals, administering medications, etc.
6. I have the right to request my formal assessment score report (CASAS, TABE, GED).
7. LANEFL is an equal opportunity provider and does not discriminate based upon an individual's race, color, national origin, sex (including pregnancy), religion, age, marital status, sexual orientation, gender identity or expression, handicap, disability, or veteran status.

Student Signature

Clear

Parent or Guardian Signature

Clear

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