English as a Second Language Registration

​LPAC TEACHES ENGLISH REGISTRATION
Name                                                                                                         
Americanized Name (if any)_______________________________________
Address                                                                                                     
 ________________________________________________________
Birthdate__________________________
Phone #___________________Cell#________________
Email_________________________________________________________
How long have you been living in the United States?____________________
Completed years of education______________________________________
Elementary School______High School________University/College_______
Native language_________________________________________________
Other Languages Spoken__________________________________________ Native Country_________________________________________________
Language Goals_________________________________________________
How did you hear about our ESL Classes?
          Mail_____Flyer_____Signs_____Internet_____Other_______
When will you begin attending?____________________________________
                                                                                Classes: Wednesday 7:00 – 9:00 pm
                                                                                                     Sunday 8:30 – 10:30 am
Today’s Date_____________
Please fill out this form and mail it to:
LifePointe Alliance Church
2298 Rochester Road
Pittsburgh, PA 15237
 
Follow us on Facebook or at www.lifepointealliance.org
Email: lifepointeesl@gmail.com