Student Application Form

STUDENT APPLICATION
Complete the student application and English placement test.

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!

Date

MonthDayYear
Date
First Name*
Last Name*
GENDER*

MaleFemale
BIRTH DATE*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*

Area CodePhone Number
Email*
example@example.com
The best way to contact me is by:

TextEmailPhone call (AM)Phone call (PM)
Country of Origin*
Language Spoken:*
Highest Level of Education:*

Elementary SchoolMiddle SchoolHigh SchoolCollege/UniversityPost-GradTechnical
Current Employment/Job:*
Previous Career:
Work in your home country. Example: student, lawyer, construction, mother, doctor, factory, farming
Comfort Level with using English:*

Very UncomfortableUncomfortableComfortableVery Comfortable
Why do you want English classes? Check all that apply.*

Better WorkCitizenshipChildren's EducationCommunity IntegrationOther:
Do you have children?

Yes. 1-5 years old.Yes. In school K-12Yes. 18+ years old.No.
How did you hear about us?*

Friend/FamilyGoogle SearchFacebookWorld ReliefEmployerInstagram
Emergency Contact Name*
Relationship of Emergency Contact*
Emergency Contact Phone Number:*
Class Course Selection (Check all that apply):*

Speaking Well in the U.S. Monday and Wednesday morning 9:30-11:30amEnglish for Life & Work Tuesday and Thursday morning 9:30-11:30amEnglish for Life & Work Monday and Wednesday evening 6:30-8:30pmSpeaking Well in the U.S. Tuesday and Thursday evening 6:30-8:30pmAmerican Accents Tuesday afternoon 6:00 to 8:00pmPrivate Lessons (4 hours/month 1x1, $200)Any morning class 9:30-11:30amAny evening class 6:30-8:30pm
What 1-2 areas I want to improve most about my English:

speaking/listeningpronunciationvocabularywritingreading
I understand that I will not be able to change my class schedule after week 2.*

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

Yes, I understandNo, I do not understand
The cost for a 10-week course meeting, 4 hours weekly and your textbook, is $435 total. You may pay in full or use the payment plan and pay monthly: 1st month - $195, 2nd month - $120, 3rd month - $120 What do you prefer?*

Pay full course fee of $435 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.
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
Payment Policy
If you agree to the payment policy above, please sign here:
Signature*

Clear

My First Step*

Registration Fee$50.00

New students: 1-time registration fee. Returning students: $50 applied to first month's payment

Enter coupon

Total $0.00

Credit Card

* Registration Fee is non-refundable. Thank you for your understanding!
Should be Empty:

STUDENT APPLICATION

Media Release

Payment Policy

Credit Card