Today's Date

First Name

Last Name

Email

Phone number

Birthdate

Current age

Place of Birth

Address

Are you a new student or returning student?

NewReturning

How did you hear about DeNeuville Learning Center for Women?

Race or ethnic background

African decent/BlackAmerican IndianAsian/Pacific IslanderHispanic origin/LatinaMiddle Eastern/ArabicWhite (not of Hispanic origin)Other

What is your marital status

Never married (single)Legally marriedLiving as married (common law marriage)SeparatedDivorcedWidowed

Class you are interested in

ESL (English as a Second Language)HiSet/GED in EnglishHiSet/GED in SpanishComputer StudiesCitizenship Test Preparation

What class time would you prefer?

MorningEvening

Did you receive a high school diploma or a GED in the US or another country?

yesno

Highest level of school completed?

Number of children

Do you need child care while in class?

yesno

If yes, how many children and what are their ages?

Please specify household/family income for the year

Less than $10,000$10,000-$20,000$20,001-$30,000More than $30,000

Employment

Full timePart timeSelf-employedUnemployedRetired

Place of employment

First Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Release of Liability ***Read Before E-signing***

In consideration of being allowed to participate in any way in the program, related events and

activities, I the undersigned, acknowledge, appreciate, and agree that:

1. The risk of any injury from the activities involved in the program or using any exercise

equipment.

2. I knowingly and freely assume all such risks, both known and unknown and assume full

responsibility for my participation.

3. I willingly agree to comply with the policies presented to me at admission. If I observe any

unusual significant hazard during my presence or participation, I will remove myself from

participation and bring such to the attention of the director/staff/volunteer immediately.

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin,

hereby release, indemnify, and hold harmless its officers, officials, program directors,

agents and/or employees, other participants, sponsors, advertisers, and if applicable,

owners from any and all claims, demands, losses, and liability arising out of or related to

any injury, disability or death I may suffer, or loss or damage to person or property to the

fullest extent permitted by law.

I have read this release of liability, fully understand its terms and sign it freely and

voluntarily without any inducement.

Type Name for Signature

Age

Date

Upload Photo ID (required)

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