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2015 ESL Class Registration Form
*
Indicates required field
Student Name
*
First
Last
Chinese Name
*
Please type the child's Chinese name, if he or she has one. If not, simply type, "None."
Birth Day
*
Gender
*
Male
Female
Email
*
Phone Number
*
Mailing Address
*
Line 1
Line 2
City
State
Zip Code
Country
Father's Name (Please fill out this form, If student under 18 years old)
*
First
Last
Email
*
Phone Number
*
Mother's Name (Please fill out this form, If student under 18 years old)
*
First
Last
Email
*
Phone Number
*
ESL Classes
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Choose One
ESL I
ESL II
Question or Comment
*
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