ESL Online Registration

Registration Form

Last Name * First Name * Middle Initial Street Address * City * State * Select an option:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * County * Select an option:AdamsAlexanderBondBooneBrownBureauCalhounCarrollCassChampaignChristianClarkClayClintonColesCookCrawfordCumberlandDeKalbDe WittDouglasDuPageEdgarEdwardsEffinghamFayetteFordFranklinFultonGallatinGreeneGrundyHamiltonHancockHardinHendersonHenryIroquoisJacksonJasperJeffersonJerseyJo DaviessJohnsonKaneKankakeeKendallKnoxLa SalleLakeLawrenceLeeLivingstonLoganMcDonoughMcHenryMcLeanMaconMacoupinMadisonMarionMarshallMasonMassacMenardMercerMonroeMontgomeryMorganMoultrieOglePeoriaPerryPiattPikePopePulaskiPutnamRandolphRichlandRock IslandSalineSangamonSchuylerScottShelbySt. ClairStarkStephensonTazewellUnionVermilionWabashWarrenWashingtonWayneWhiteWhitesideWillWilliamsonWinnebagoWoodford Home Phone Cell Phone * Personal Email * Prairie State College email (returning and continuing students only) Where do you live? * Select an option:Rural AreaUrban (City) with high unemploymentNeither Social Security No. Student ID No. Gender * Select an option:MaleFemaleOther (specify) Other Date of Birth * Marital Status * Select an option:SingleMarriedDivorcedWidowUnknown Do you receive public assistance (medical card)? * Select an option:YesNo Public Assistance Medical Card No.

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Emergency Contact Information

Name * Relationship * Phone *

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Residency Status * Select an option:In DistrictOut-of-District Enrollment Status * Select an option:First time studentReturning student

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Ethnic Background

Is English your primary language? * Select an option:YesNo If no, what is your native language? Native country? Select your country: Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo - Democratic Republic of Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equitorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guyana French Polynesia French Southern and Antarctic Lands Gabon Gambia Gaza Strip Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia - Federated States of Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands North Korea Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthélemy Saint Kitts and Nevis Saint Lucia Saint Martin (French Part) Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch Part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia & South Sandwich Isl. South Korea South Sudan Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Isl. United States Virgin Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna West Bank Western Sahara Yemen Zambia Zimbabwe European Union

Race and Ethnicity

Are you of Hispanic, Latino, or of Spanish origin? * Select an option:NoYes Please identify your primary racial/ ethnic group. (Select one) * Select an option:American Indian or Alaska NativeAsianBlack or African AmericanHispanic/LatinoNative Hawaiian or Other Pacific IslanderWhite

Are you from one or more of the following racial groups? (Select all that apply)

American Indian or Alaska Native Black or African American Native Hawaiian/Pacific Islander White

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Are you a veteran? * Select an option:YesNo

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Highest Degree Earned * Select an option:1. None2. GED3. High school diploma4. Some college5. Certificate6. Associate’s degree7. Bachelor’s degree8. Master’s degree9. Doctoral degree10. Other (complete next field)11. Foreign degree Other Degree Year degree was earned (if known)

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Parent's Educational Background (Please choose one option.) * Select an option:1. None2. GED3. High school diploma4. Some college5. Certificate6. Associate’s degree7. Bachelor’s degree8. Master’s degree9. Doctoral degree10. Other Indicate year, if known.

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Additional Student Information

Where did you attend school in the past? * Select an option:In the USIn a different country Number of years completed * Select an option:No SchoolingGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12HS Diploma/Alternative CredentialGED CertificateSome College Courses/No DegreeCollege or Professional DegreeUnknown Do you have a GED from the U.S.? NoYes Check this box to give us permission to obtain your GED test results. * Do you have a high school diploma from the U.S.? NoYes

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Did you receive a referral from a WIOA Core Partner or One-Stop? * Select an option:NoYes If yes, what is the name of referring WIOA Partner/One-Stop?

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Will you require accommodations? * Select an option:Not DisabledDocumented Disability as defined by ADAChooses not to Disclose Employment Status * Select an option:Not in labor forceUnemployedEmployed If employed, how many hours are worked per week? Barriers to Employment * Select an option:English Language Learner, Low Literacy Levels, Cultural BarriersIndividual with a DisabilityEx- OffenderVeteranLow IncomeSingle ParentNot Applicable

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What is your goal for taking English class at Prairie State College? * Select an option:Improve English language skillsObtain CitizenshipGet my Illinois High School Diploma (GED)Get a jobKeep my current jobGet a promotion in my jobGo to collegeObtain a certificate (Forklift, Automotive, etc.)Other (specify below) Other:

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Career Pathways

Are you interested in one of these careers? * Select an option:AutomotiveEmergency Medical Technician (EMT)Forklift CertificationHealthcare (CNA)HVACInformation Technology (IT)WeldingOther (specify below) Other:

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Class Preference

Please select a class(es):

ESL (English as a Second Language) Citizenship HSE (GED) en Español

Do you prefer class on-campus or online? * Select an option:On-campusOnlineBoth Do you prefer class in the morning or evening? Classes meet two days a week. * Select an option:Morning: 9:30 a.m.-12:30 p.m.Evening: 6:30-9:30 p.m.Both Signature *