Learner Contact Form -

First and Last Name

Phone Number–IMPORTANT–Please double-check your phone number. We need it to contact you.

Street Address (Number and Street)

City

State

Zip Code

Date of Birth

What is the main language you speak?

What country are you from?

Best Way to Contact You

Phone

Best Time to Contact You (check all that apply)Choose several options

Mornings

Afternoons

Evenings

Are there any times during the week that you are NOT available. Please list them.

What is the highest grade or level of school you have completed?

Was that schooling in the U.S.?(required)

Yes

Do you have a job? (Choose one)(required)

NO-I am unemployed

YES-I have a part-time job

YES-I have a full-time job

My MAIN goal for studying at DCLC is… Please choose only one.(required)

Improve my reading and writing

Improve my math skills

Learn English or improve my English

Get my GED

Other (please explain below)

Other Goal? Please explain here.

How long have you lived in the U.S.?

Do you have a computer, laptop, tablet, or phone to use for classes?Choose one option(required)

Yes

Do you have Internet/Wifi access?(required)

Yes

Not Sure