This form is developed for, and to be used by the English Spot in order to process the new student admission. Applicant must complete this form and provide accurate information to be eligible for this program. SECTION 1. PERSONAL INFORMATION Full Name Date of Birth —Please choose an option—MaleFemaleOther Gender Address City State Zip Code [text * MobilePhone] Mobile Phone Work Phone Home Phone Email Address Social Last 4 Numbers Country of origin Country of residence SECTION 2. ACADEMIC INFORMATION —Please choose an option—HIGH SCHOOLBACHELOR DEGREEDOCTORAL DEGREEASSOCIATE DEGREEMASTER DEGREEOTHER Education Level —Please choose an option—YESNO Are you currently enrolled in School? If your answer is affirmative, please specify —Please choose an option—YESNO Are you currently employed? SECTION 3. LANGUAGE What is your Native Language? —Please choose an option—YESNO Do you speak another language? If your answer is affirmative, please specify EMERGENCY CONTACT INFORMATION FOR STUDENTS This information will be extremely important in the event of an accident or medical emergency. Please be sure that the information you provide is accurate. Student's Full Name [text * MobilePhone] Mobile Phone Home Phone In case of an emergency, please contact Primary Emergency Contact Name Relationship Home Phone [text * MobilePhoneEmergencyContact] Mobile Phone Work Phone E-mail Secondary Emergency Contact Name Relationship Home Phone Mobile Phone Work Phone E-mail Preferred Local Hospital ALLERGIES INFORMATION I agree to take all necessary precautions and actions to ensure the security and confidentiality of the English Spot Placement test. I agree NOT to reproduce or copy, in any fashion, in whole or part, any of the materials of the English Spot system. I acknowledge that all said materials are copyrighted, and I agree NOT to share, in any way, such materials with any unauthorized persons. Check the one that applies: I, hereby certify I do not want to take the Placement Test offered to me by the English Spot in order to know my proficiency level. My direct request to the English Spot is to enroll me in their basic level. I want to be part of their basic level so that I get all the proper ESOL basics.
