Adult Education Registration Form

Thank you for your interest in Adult Education classes at Trellus!

Steps to enroll in Trellus’ in-person, morning classes:

1. Complete the following Registration Form.

2. Come to Trellus (2838 W. Peterson Ave. Chicago, IL 60659) on Wednesday, December 11th, between 10:00 AM to 2:00 PM to take an English Speaking, Writing, and Reading test to determine your class placement. The testing will take around 2-3 hours to complete.

Steps to enroll in Trellus’ online, evening classes:

1. Complete the following Registration Form.

2. If you can come in-person to Trellus (2838 W. Peterson Ave. Chicago, IL 60659), please come on Wednesday, December 11th, between 10:00 AM to 2:00 PM to take an English Speaking, Writing, and Reading test to determine your class placement. The testing will take around 2-3 hours to complete.

3. If you cannot come in-person to take your placement tests, please send an email to adulted@mytrellus.org.

In-Person Registration Day:

Wednesday, December 11th, from 10:00 AM to 2:00 PM

Winter term dates: January 6th - March 20th, 2025 (11 weeks)

Please type your answers in English.

Пожалуйста, пишите свои ответы на английском языке.

Por favor conteste en inglés

الرجاء كتابة الإجابات باللغة الإنجليزية

Which class are you interested in....?

First Name

Last Name

Date of Birth

Do you have any children?

YesNo

If yes, what are their ages?

Are you a CPS Parent?

YesNo

Are you part of the Chicago Connected Program?

YesNo

Do you have a Social Security Number?

YesNo

Please provide your Social Security Number

Country of Origin (Home Country)

Native language (first language)-may be more than 1

Are you Hispanic or Latino? (Are you of Spanish origin?)

YesNo

Contact Information

Must live in Chicago or the neighboring suburbs

Mailing Street

City

State

Zip Code

Phone Number

Email Address

Emergency Contact

Name of Emergency Contact and Relationship (Example: David Smith - husband)

Phone Number of Emergency Contact

Education

Did you attend school in the past?

Yes, NOT in the U.S.Yes, in the U.S.No

Number of school years completed (check one)

Do you have a GED or HS diploma from the United States?

YesNo

Do you work?

Not WorkingWorking Full TimeWorking Part TimeEmployed, received notice of termination or Military Separation

What is your occupation (or job) if you are working?

If you are working, who is your employer? (Example: Avamere, McDonald's, Hilton Hotels...)

If you are employed, how many hours do you work per week?

What is your monthly income?

Other

Disability?

YesNoI don't want to say

Disability Description

If "Family/Friend", please provide the name:

Do you receive Public Assistance (like government health care, food stamps/link card....)?

YesNoI'm not sure

Do you have internet access at home?

YesNo

What devices that connect to the internet do you have at home?

Desktop computerLaptopTabletSmartphone

Goals

All students must choose a career pathway to learn more about in their English studies or explore in the future.

Choose 1 or 2 areas that you want to learn more about

Choice 1 from the picture above that you want to learn more about

Choice 2 from the picture above that you want to learn more about (not required)

Final Questions

Before students begin classes they need to complete a placement test. What is the best way to contact you to schedule a call (computer class) or speaking test (ESL)?

CallText MessageEmail

When is a good time to contact you?

Morning (9:00-11:00)Afternoon (12:00-3:00)Later afternoon (4:00-6:00)

Do you have any questions or comments?

I give my permission to use my name, likeness, image, and/or voice for promotional or educational materials.

YesNo

By signing this registration form, I agree to the attendance policy and rules of the LEAF Program. Please type your name below for a signature.

Trellus Adult Education