ESL Online Registration
Step 1 of 2: Submit
Term
*
Select an option:
Summer
Fall
Spring
Term Year
*
Select an option:
2022
2023
2024
Registration Form
Last Name
*
First Name
*
Middle Initial
Street Address
*
City
*
State
*
Select an option:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
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Hawaii
Idaho
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
County
*
Select an option:
Adams
Alexander
Bond
Boone
Brown
Bureau
Calhoun
Carroll
Cass
Champaign
Christian
Clark
Clay
Clinton
Coles
Cook
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Cumberland
DeKalb
De Witt
Douglas
DuPage
Edgar
Edwards
Effingham
Fayette
Ford
Franklin
Fulton
Gallatin
Greene
Grundy
Hamilton
Hancock
Hardin
Henderson
Henry
Iroquois
Jackson
Jasper
Jefferson
Jersey
Jo Daviess
Johnson
Kane
Kankakee
Kendall
Knox
La Salle
Lake
Lawrence
Lee
Livingston
Logan
McDonough
McHenry
McLean
Macon
Macoupin
Madison
Marion
Marshall
Mason
Massac
Menard
Mercer
Monroe
Montgomery
Morgan
Moultrie
Ogle
Peoria
Perry
Piatt
Pike
Pope
Pulaski
Putnam
Randolph
Richland
Rock Island
Saline
Sangamon
Schuyler
Scott
Shelby
St. Clair
Stark
Stephenson
Tazewell
Union
Vermilion
Wabash
Warren
Washington
Wayne
White
Whiteside
Will
Williamson
Winnebago
Woodford
Home Phone
Cell Phone
*
Personal Email
*
Prairie State College email (returning and continuing students only)
Where do you live?
*
Select an option:
Rural Area
Urban (City) with high unemployment
Neither
Social Security No.
Student ID No.
Gender
*
Select an option:
Male
Female
Other (specify)
Other
Date of Birth
*
Marital Status
*
Select an option:
Single
Married
Divorced
Widow
Unknown
Do you receive public assistance (medical card)?
*
Select an option:
Yes
No
Public Assistance Medical Card No.
A copy of your public assistance card will be required.
Emergency Contact Information
Name
*
Relationship
*
Phone
*
Residency Status
*
Select an option:
In District
Out-of-District
Enrollment Status
*
Select an option:
First time student
Returning student
Ethnic Background
Is English your primary language?
*
Select an option:
Yes
No
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:
No
Yes
Please identify your primary racial/ ethnic group. (Select one)
*
Select an option:
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
White
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
Are you a veteran?
*
Select an option:
Yes
No
Highest Degree Earned
*
Select an option:
1. None
2. GED
3. High school diploma
4. Some college
5. Certificate
6. Associate’s degree
7. Bachelor’s degree
8. Master’s degree
9. Doctoral degree
10. Other (complete next field)
11. Foreign degree
Other Degree
Year degree was earned (if known)
Parent's Educational Background (Please choose one option.)
*
Select an option:
1. None
2. GED
3. High school diploma
4. Some college
5. Certificate
6. Associate’s degree
7. Bachelor’s degree
8. Master’s degree
9. Doctoral degree
10. Other
Indicate year, if known.
Additional Student Information
Where did you attend school in the past?
*
Select an option:
In the US
In a different country
Number of years completed
*
Select an option:
No Schooling
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
HS Diploma/Alternative Credential
GED Certificate
Some College Courses/No Degree
College or Professional Degree
Unknown
Do you have a GED from the U.S.?
No
Yes
Check this box to give us permission to obtain your GED test results.
*
Do you have a high school diploma from the U.S.?
No
Yes
Did you receive a referral from a WIOA Core Partner or One-Stop?
*
Select an option:
No
Yes
If yes, what is the name of referring WIOA Partner/One-Stop?
Will you require accommodations?
*
Select an option:
Not Disabled
Documented Disability as defined by ADA
Chooses not to Disclose
Employment Status
*
Select an option:
Not in labor force
Unemployed
Employed
If employed, how many hours are worked per week?
Barriers to Employment
*
Select an option:
English Language Learner, Low Literacy Levels, Cultural Barriers
Individual with a Disability
Ex- Offender
Veteran
Low Income
Single Parent
Not Applicable
What is your goal for taking English class at Prairie State College?
*
Select an option:
Improve English language skills
Obtain Citizenship
Get my Illinois High School Diploma (GED)
Get a job
Keep my current job
Get a promotion in my job
Go to college
Obtain a certificate (Forklift, Automotive, etc.)
Other (specify below)
Other:
Career Pathways
Are you interested in one of these careers?
*
Select an option:
Automotive
Emergency Medical Technician (EMT)
Forklift Certification
Healthcare (CNA)
HVAC
Information Technology (IT)
Welding
Other (specify below)
Other:
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-campus
Online
Both
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
We will do our best to accommodate your preferences.
Signature
*
Date:
Saturday, 20 April 2024 (EDT)
Name:
Type your name to sign this document:
Typing name is equivalent to a handwritten signature
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