Returner Student Form NEW

Returner Student

Enrollment Process
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

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)!
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?

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
7. Emergency Contact Name*
8. Relationship of Emergency Contact*
9. Emergency Contact Phone Number:*
10. Class Course Selection (Check all that apply):*

Speaking Well in the US (Monday & Wednesday morning 9:30-11:30 a.m.)Speaking Well in the US (Monday & Wednesday evening 6:30-8:30 p.m.)English for Life and Work (Tuesday & Thursday morning 9:30-11:30 a.m.)English for Life and Work (Tuesday & Thursday evening 6:30-8:30 p.m.)Private Lessons (1x1, 4 hours per week or month; $200)
11. I understand that I will not be able to change my class schedule after week 1.*

Yes, I understandNo, I do not understand
12. Last attended cycle
(Example: Fall Cycle 2023, Summer Cycle 2023, Winter Cycle 2022)
13. How do you prefer to pay for the cycle?

Pay full course price $480 (discount will be applied if applicable)Pay 3 monthly payments on due date; 1st payment is $200 (discount will be applied to 3rd payment if applicable)
14. How do you prefer to pay ?

Card (CLC staff will send you an invoice)Cash (in person)
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.
14. 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
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: *

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

Clear
* 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:

Returner Student

Media Release