2. Enrolled Students NEW

Enrollment Process
Complete the survey and you will be ready to start English Class.

It is recommended to be COVID vaccinated to attend classes.
Connect Language Center staff will contact you to confirm your class schedule and answer any questions.
Set up your payment plan!
1. Date

MonthDayYear
Date
2. Full Name*

First NameLast Name
3. Cell Phone Number*

Area CodePhone Number
4. Email*
example@example.com
5. Birth Date*

MonthDayYear
6. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
7. Gender*

MaleFemale
8. Are you a New or Former Student?

I'm a new Student!I was a student before (Former Student)!
9. Country of Origin*
10. Did you come to the US as a refugee or asylee with an I-94 less than 5 years ago?

NoYes
11. Language Spoken:*
12. Highest Level of Education:*

Elementary SchoolMiddle SchoolHigh SchoolCollege/UniversityPost-GradTechnical
13. Current Employment/Job:*
14. Previous Career:
Work in your home country. Example: student, lawyer, construction, mother, doctor, factory, farming
15. Why do you want English classes? Check all that apply.*

Better WorkCitizenshipChildren's EducationCommunity IntegrationOther:
16. How did you hear about us?*

Friend/FamilyGoogle SearchFacebookWorld ReliefEmployerInstagramOther
17. Emergency Contact Name*
18. Relationship of Emergency Contact*
19. Emergency Contact Phone Number:*
20. Class Course Selection (Check all that apply):*

Monday and Wednesday morning 9:30-11:30amTuesday and Thursday morning 9:30-11:30amMonday and Wednesday evening 6:30-8:30pmTuesday and Thursday evening 6:30-8:30pmPrivate Lessons (4 hours/month 1x1, $200)Any morning class 9:30-11:30amAny evening class 6:30-8:30pm
21. I understand that I will not be able to change my class schedule after week 1.*

Yes, I understandNo, I do not understand
22. I understand that I am in a group class and there is an inherent risk due to the ongoing pandemic*

Yes, I understandNo, I do not understand
23. What do you prefer to pay for the Cycle?*

Pay full course fee of $480 once.Pay 3 monthly payments on due date.
Media Release
By signing this form, I give Connect Language Center/WR permission to use pictures with me in them or other information, to publically share about the good things that are happening here. This includes possible use on the Instagram/social media, newsletters/printed material, or the website.

I understand I will not get paid for any pictures with me in them, and I release the CLC/World Relief from any future claims or liability from using the above.
23. I give permission for Connect Language Center/WR to use:*

Photographs/video of me (Instagram/Facebook)I do not give permission for pictures of me
I understand I will not get paid for any pictures with me in them, and I release the CLC/World Relief from any future claims or liability from using the above.
Signature: *

Clear
24. Payment Policy

If you pay during the next 5 days from the payment due date CLC will not charge any additional fee. But you pay after the 5th day of your payment due day CLC will charge $25 extra fee.
If you agree to the payment policy above, please sign here:
Signature*

Clear

25. My First Step*

First Payment $200.00

This will be the first payment for your Cycle.

Enter coupon

Total $0.00

Credit Card

* if you have any questions please contact to (901)-295-8874 or send an email to info@connectefl.com. Thank you for completing you enrollment, see you in class!
Should be Empty:

Enrollment Process

Media Release

24. Payment Policy

Credit Card