Returner Student Form NEW

Complete the form and you will be ready to start English Class.

Connect Language Center staff will contact you to confirm your class schedule and answer any questions.

Set up your payment plan!

1. Date

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

8. Are you a New or Former Student?

7. Country of Origin

8. Did you come to the US as a refugee or asylee with an I-94 less than 5 years ago?

11. Language Spoken:

12. Highest Level of Education:

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.

16. How did you hear about us?

7. Emergency Contact Name

8. Relationship of Emergency Contact

9. Emergency Contact Phone Number:

10. Class Course Selection (Check all that apply):

11. I understand that I will not be able to change my class schedule after week 1.

12. Last attended cycle

(Example: Fall Cycle 2023, Summer Cycle 2023, Winter Cycle 2022)

13. How do you prefer to pay for the cycle?

14. How do you prefer to pay ?

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.

14. I give permission for Connect Language Center/WR to use:

Media Release 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:

If you agree to the payment policy above, please sign here:

Signature

* 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!