Name *

First Name

Last Name

Phone

(###)

###

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Student Status (required) *

I certify that I am at least 19 years old

Childcare Needs

I will need childcare while in class.

What is your level of English proficiency? *

Beginning (No or limited English)

Basic (Can read, write, and speak some English )

Intermediate (Can read, write, speak English with mistakes)

Advanced (Can read, write, speak, English with few mistakes)