Salida Regional Library, ESL Class, Spring 2023

Date:
January 17, 2023 - 3:26PM

Location:
Salida Regional Library
405 E. St.
Salida, CO 81201

Instructor:
Charlie Verhoeven

Register

1. First Name:

2. Middle Name:

3. Last Name:

4. Pronouns:

5. Gender Identity:

6. Program:

7. Birth Date:

8. Sex:

* Learners identifying as Non-binary or preferring not to respond will be randomly assigned the Male and Female sex reporting categories by an algorithm in the state Student Information System for the purposes of Federal reporting.

9. Ethnic Background:

10. Ethnic Background (check all that apply):

American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White Please make at least one selection

11. Country of Birth:

The United States Outside the United States: Country:

12. Educational Background:

No Schooling Last Grade Completed: High School Diploma or GED Some Postsecondary Education (no degree) College or Professional Degree Unknown

13. Attended School in:

The United States Outside the United States

14. Employment Status:

15. Barriers (check all that apply):

Cultural Barriers Disabled Displaced Homemaker Economic Disadvantage (Low Income) English Language Learner Ex Offender Low Levels of Literacy Exhausting TANF within two years Homeless Long-term Unemployed Migrant Farmworker Seasonal Farmworker Single Parent or Guardian Please make at least one selection

16. Address:

17. Address 2:

18. City:

19. County:

20. State:

21. Zip Code:

22. Social Security NumberSSN (not required):

23. Phone:

24. Email:

25. Yearly Household Income:

26. Specific Status (check all that apply):

On Public Assistance Dislocated Worker Immigrant Minor with Adult Status

27. My primary goal for attending class is to:

Improve English Skills Improve Basic Literacy Skills Earn a GED Enter a Postsecondary Education or Job Training Obtain a Job Retain Current Job Improve Current Job Other:

28. I heard about classes from:

A friend My job Local Community College A flyer/poster Other:

I authorize the release of information on the enrollment form as well as testing information to representatives of the Colorado Department of Education, The Colorado Department of Labor and Employment, The Learning Source and other funders and partners. I understand this information will be used for program evaluation purposes only. This authorization will remain in effect for the duration of the program. I also understand giving my social security number is voluntary. The number may be used to match information between state agencies. It will not be used to make decisions about myself or any other person. I understand I will not lose any rights as a student if I do not give my social security number.

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The Learning Source
929 29th Street
Denver, CO 80205
info@thelearningsource.org
Phone: 303-957-2838

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