Date:____________________________

Title: Mr. / Mrs. / Ms. / Miss / Dr. / Other _____________ (Please circle)

First Name:_______________ Middle Name:__________ Last Name:__________________
(Given Name)--------------------------(or Initial)-------------------------(Family Name)

Country of Origin:____________________________

Mailing Address:______________________________________________________________

City:_____________________________ State:______ Zip Code:______________________

Phone number:_______________________________________

Languages you speak:________________________________________________________

What language do you speak at home?___________________________________________

How long have you lived in the United States?____________________________________

Other classes you are enrolled in:_______________________________________________

What do you most want to learn in this class?_____________________________________
_________________________________________________________________________
_________________________________________________________________________

Where did you learn about this class?_______________________

Did you see a flyer in the library? ________

Did you see a notice in the newspaper?___________ Which paper?__________

Did someone tell you about the class?____________Who?_________________