Prospective Learner Questionnaire
Name:
Phone:
Email:
Address:
How did you hear about our program?
Select answer
Online
Referral
Other
Are you at least 18 years old?
Yes
No
Where do you currently live?
Select answer
Newport Beach
Irvine
Other
Did you move to the U.S. from another country?
Yes
No
How long have you lived in Orange County?
How long do you plan to remain in the U.S?
Do you plan to travel internationally during the year?
Yes
No
Where did you attend high school?
Have you participated in an ESL program?
Yes
No
Are you currently working?
Yes
No
No, but I am interested in finding a job
Are you in school?
Yes
No
No, but I am interested in school or college
Are you a stay-at-home parent?
Yes
No
What aspect of the program are you interested in?
Only Tutoring
Only Classes
Both
Are you willing to meet at the Newport Beach Library for tutoring or class services?
Yes
No
How do you think our program can help you? Check all that apply:
Work
School
Family
Community
Submit