Student Enrollment Form

Student Enrollment Form
Thank you for signing up for free classes at the Literacy Council of White County, Arkansas! If you have any questions about this form, call us at 501-278-5500.
First Name
Last Name
Date of Birth
Phone Number
Cell Phone Number
Address
City
State
Zip Code
Emergency Contact Name
Emergency Contact Number
Age

18 or under19-2425-4445-5960 or older
Gender

MaleFemale
Ethnicity

American Indian/Alaskan NativeAsianNative Hawaiian/Pacific IslanderBlack/African AmericanHispanic/LatinoWhite/CaucasianOther
Highest Education Level

Less than High School Diploma/GEDHigh School Diploma/GEDSome CollegeUndergraduate DegreeGraduate Degree
Employment Status

EmployedUnemployedRetiredDisabledHomemakerCurrent MilitaryVerteran
Do you have a documented learning disability?
What days can you take classes?

MondaysTuesdaysWednesdaysThursdaysFridays
What times can you take classes

Mornings (Until 12)Afternoons (12-5)Evenings (5 or later)
What class are you interested in?

Adult Basic LiteracyEnglish as a Second LanguageEmployable (Job Skills)
Is there anything else that we need to know?
Should be Empty: