Nicerfl · NicerFL Registration Form

Contact Information

Name

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First Name

Last Name

Email

*

Verify Email

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Phone

*

Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Registration Details

Are you a new immigrant who came in the last 5-8 years and is still learning English and adapting to the life in the US?

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Can your tutor/mentor contact you by phone and email related to your studies in the program?

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Phone

Email

No

What is your ethnicity?

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American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or other Pacific Islander

White

Other

What is your country/nationality?

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How many people live in your household?

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How many children do you have?

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When did you arrive in the United States?

(mm/dd/yyyy)

Select the highest level of education completed?

No school

Year 9-12 (No diploma)

High School Diploma

Some College

College or Professional degree

How many hours do you work a week?

I don't work

10-20

20-30

Full time 40+

Enrollment in our program is based on the new immigrant student need and tutor availability. Students with lowest family income and English language proficiency will be enrolled first. What is your monthly family income?

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Programs

As a new immigrants, what programs are you interested in?

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English as a Second Language - online groups

In person English and Academic tutoring for immigrant school age kids

Online individual tutoring -school age kids and adults

In person English Conversation Club

Career Resources and preparation (look for a job, applications, resume, other)

Family and Community Resources and Information(Health, forms and applications, financial literacy, education)Option 6

Translation or Interpreter

Individual Mentoring

Other

Reasons to be a NICERFL Student

How did you hear about our organization?

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Why do you want to become our student? How are we different from other immigrant education organizations? If you can't speak English well, please provide a detailed answer in your language.

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Consent and Waiver of Responsibility

I give my permission for the NICERFL to film and/or record me or my family during any activity or class. NICERFL may use the pictures or recordings to promote its activities. If you don't consent to this, you may not use your video during tutoring session

*

Yes

No

Waiver for Signature

I hereby waive any claims against, and RELEASE AND HOLD HARMLESS AND INDEMNIFY NicerFL and any of their employees, staff, volunteers, agents and representatives from any liability, claim, loss, damage, cost or expense arising from my participation in this event. I waive such claims against such organization or any such person, arising directly or indirectly from or attributable in any legal way, to any action or omission to act of any such organization or person in connection with execution of this event. I authorize treatment by a licensed medical physician or licensed medical team in case of any accident or illness that may so arise, or any hospitalization necessary.

I hereby certify that the information I have provided on this form is accurate to the best of my knowledge. Please provide your name and today's date as verification.

Please sign your full name and date if you agree.

Signature

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Date

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(mm/dd/yyyy)

I understand that if I bring my children, and they cannot be enrolled in our Newcomer Student Tutoring Program, I must supervise my children at all times and accompany them outside the room. They have to sit quietly in the room with you at all times.

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Yes

No

Health Agreement

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I understand that if I have concerns for my health related to the spread of COVID-19, I can wear a mask during the sessions. If I contract the disease, I must inform the Program Manager immediately, follow CDC guidelines and stop coming to the sessions until it is safe to do so to protect the other students.

Yes

No

I understand that I have to attend the program I am enrolled in for at least 24 hours (3 months). I will be dismissed if I am absent more than 6 hours without a good reason.

*

Yes

No