ELL Student Registration

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Name *

Address *

Phone number *

Email *

Birthdate:

YYYY

Gender

Male

Female

Prefer not to say

Other:

Clear selection

Where were born?

How long have you lived in Canada?

In your native country, what is the highest grade you went to?

Are you a:

Canadian

Permanent Resident

Visa

Clear selection

What is your goal?

How did you learn to speak English?

What are the best day(s) and time(s) to meet with a teacher? *

Do you have a laptop/computer/smartphone to use for classes?

Yes

Clear selection

Please tell us how you found out about our classes.

Agency (such as YMCA)

School

Family/Friend

Internet

Library (staff, website, poster)

Media (newspaper, social media)

Word of Mouth

Clear selection

Emergency Contact Name *

Emergency Contact Phone Number *

Email Consent: I give the library permission to either email me program information or share my email address, as required, with my tutor(s).

Yes

Clear selection

Media Release Form

I grant permission to Parry Sound Public Library to take and use digital images and/or photographs of myself for use in various printed publications, websites to promote the Libraries programs and services including use on social media and print. I authorize the use of these images without compensation to me. All negatives, prints, digital reproductions shall be the property of Parry Sound Public Library.

I agree that my name may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images without compensation to me. All negatives, prints, digital reproductions shall be the property of Parry Sound Public Library.

Acknowledgement *

I acknowledge that I have read and fully understand this form and these consents. If I want to change my consents, I will talk to Parry Sound Public Library staff.

Required

Submit

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