EmailMe Form - ELL STUDENT ENROLLMENT FORM

Name *
First MI Last
Nickname/Preferred Name
Preferred Phone # *
### - ### - ####
Address *
Street Address
*
State
*
City
*
Zip Code
I have a social security number *
Yes
No
Social Security Number
Email *
Emergency contact phone number *
Emergency contact name *
Can we talk about your education/goals with your emergency contact/English speaker? *
Yes
No
Birthdate *
MM / DD / YYYY
Gender *
Male
Female
Have you ever attended English class? *
Yes
No
Where?
Online
Gashland Church
Northgate
Norclay
Maple Woods
North Cross Church
Don Bosco
Other
Are you Hispanic/Latino? *
No, not Hispanic/Latino
Yes, Hispanic/Latino (A Person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture of origin, regardless of race.)
What is your race? (You may choose more than one.) *
American Indian or Alaska Native (A person having origins in any of the original peoples of North & South America, including Central America, and who maintains a tribal affiliation or community attachment.)
Asian (A person having origins in any of the peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example: Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.)
Black or African American (A person having origins in any of the Black racial groups of Africa.)
Native Hawaiian or other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
White (A person having origins in any of the original peoples of Europe, the Middle East or North Africa.)
Country of Origin *
Native Language *
How long have you lived in the United States? *
Do you have an F1 Visa (student visa)? *
No
Yes
Location of highest level of education: *
In U.S.
Outside U.S.
Highest level of education completed: *
No schooling
Secondary School Equivalent (GED, HiSET, Home School)
Grades 1-5
Some Postsecondary Education, No Degree
Grades 6-8
Postsecondary or Professional Degree
Grades 9-12 (no diploma)
Unknown
Secondary School Diploma or alternate credential (High School Diploma)
Job Status (select one): *
Employed
Employed with separation notice
Unemployed (Not working but looking for a job)
Not in labor force (Not looking and not working)
Barriers to Employment (Select all that apply):
Cultural Barriers
Disabled
Dislocated Worker
Displaced Homemaker
English Language Learner
Exhausting TANF within two years
Ex-Offender
Foster Care Youth
Homeless
Low Income
Low Literacy Levels
Long-term Unemployed
Migrant Farmworker
Minor with Adult Status
Public Assistance
Seasonal Farmworker
Single Parent or Guardian
Goals: *
Obtain a job (not working)
Retain a job
Leave public assistance
Earn HSE or Secondary Diploma
Postsecondary (college)
Job Training Program
Improve Basic Literacy Skills
Improve English Language Skills
Achieve Citizenship Skills
Obtain Citizenship
Increase involvement in child's education
Help child with school work
Increase contact with child's teacher
Increase involvement in child's school/literacy activities
Visit library (with/for child)
Increase involvement in community activities
Vote or register to vote
Other personal goals
Signature *
I certify that the information given on this application is true and accurate to the best of my knowledge and belief. I consent to the release of my records maintained by a state or local education agency, including the information on this form and transcripts, grades, certificates, the High School Equivalency, and diplomas earned by me. This information may be used by the Missouri Department of Elementary and Secondary Education and shared with other state agencies for research and reporting purposes. Data shared between agencies includes, but is not limited to, employment, additional schooling, and follow-up services provided to you by agencies identified in the Workforce Innovation and Opportunity Act (2014).
Date: *
MM / DD / YYYY