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Email
Gender
Male
Female
I'd rather not say
Phone Number
Address
Apartment, suite, etc.
City
State
Postal / Zip Code
Country
Best time to contact you?
Morning
Afternoon
Evening
Do you prefer?
Phone
Text
Email
Emergency contact name
Emergency Contact number
Relationship to emergency contact?
Spouse
Parent
Child
Other family member
Friend
Are you Hispanic/Latino?
Yes
No
Are you employed?
Yes
No
How did you hear about classes?
Have you been enrolled in Adult Education Classes before?
Yes
No
Goals-Check all that apply
Obtain High School Equivalency
Improve English Oral/Speaking Skills
Improve Literacy Reading/Writing Skills
Enter Employment
Enter Post-Secondary education or job training
All of the above
Optional Goals
Increase Involvement in Children's Education
Increase Involvement in Community Activities
Leave Public Assistance
Obtain Citizenship Skills
Register to Vote or Vote
Are you interested in attending a Bible Study Group?
Yes
No
Not sure
Will anything prevent you from coming to class on a regular basis?
Yes
No
How would you rate your English speaking? 1 being low 5 being high
1
2
3
4
5
How would you rate your English writing? 1 being low 5 being high
1
2
3
4
5
Have you studied English before?
Yes
No
By submitting this application you agree to the best of your knowledge you are in good physical condition and able to participate in classroom activities with Collierville First Pentecostal Church. You voluntarily assume full responsibility for any risks, loss, property damage, or personal injury that may be sustained by yourself, or loss or damage to property owned by you, while on the premises of any location hosting Collierville First Pentecostal Church. By submitting this application you grant Collierville Pentecostal Church the right to take photos, the participation in interviews and the use of quotes. You also hereby grant to Collierville Pentecostal Church the right to edit, use and reuse photographs and videos for non-profit purposes including print, on the internet, and all other forms of media. You also hereby release Collierville Pentecostal Church, it's agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
I agree to terms and conditions
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