ESL Intake "*" indicates required fields Name* First Middle Last Date of Birth* YYYY dash MM dash DD Age*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Emergency ContactName*Phone*Gender*Please SelectMaleFemaleOtherWhat is your race/ethnicity*Please SelectHispanicBlack/African AmericanAmerican Indian/Alaska NativeWhiteBi-RacialHawaiian Native/Pacific IslanderAisaOther (Please State)Do not wish to discloseRace Other*Primary Language*Please SelectEnglishSpanishOtherCountry of Origin*Marital Status*Please SelectSingleMarriedDivorcedSeparatedWidowedVeteran* Yes No Highest Education*Please SelectGrade SchoolSome High SchoolHigh School DiplomaSome CollegeAssociate's degreeBachelor's degreeMaster's degreeGED/Other TradeOtherDo you receive any Supplemental Nutrition Assistance Program (SNAP)?* Yes No Do you have Medical Coverage?* Yes No Do you have a Criminal Record?* Yes No Employment Status*Please SelectEmployed Full TimeEmployed Full Time TemporaryEmployed Part TimeEmployed Part Time TemporaryNever EmployedUnemployedIndividual Income*AnnualHousing Status*Please SelectRentingHome OwnerHomelessOtherFamily Type*Please SelectNuclear FamilySingle parentExtended FamilyStep-FamilyGrandparent FamilyLiving aloneOtherFamily Size*How were you referred to us?*Please SelectAppointmentWalk-InLinkedInReferralFacebookFriend/Family MemberOtherEqual Opportunity Statement: Tec Centro York is committed to equal opportunities regardless of race, color, religion, sex, national origin, age, disability, sexual orientation, marital status, or legally protected.Authorization of Release of Information I agree and give consent.Photo Release FormI hereby give consent to Tec Centro York (the “Organization”) to photograph, videotape, or otherwise digitally record and use images, likenesses, photographs, videos, quotes, summaries and/or sound recordings of myself or my child or children (if applicable) (collectively, the “Images”) to use in any and all media, including radio, television, internet, social media, print or in any of the Organization’s or its partners’ publications, productions, brochures, or posts. I understand that the intended use of such Images and information is solely for the purpose of advertising, marketing, fundraising and/or the promotional and public awareness purposes for the Organization. I hereby waive any rights or interest in the Images, as contemplated in this release. I acknowledge that this consent to use Images is being made solely for the benefit of the Organization and comes without any expectation of monetary compensation or other benefit to me. To the extent that any benefit accrues or might accrue to the Organization from the use of Images or information, I hereby and forever waive any interest in or claim to such benefits. I hereby release and forever discharge the Organization (including without limitation all corporate affiliates and officers, directors, trustees, donors, employees, agents and volunteers) from any and all claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to, or in any way connected with the use of Images and materials described herein, and I hereby waive all rights and interest in and to such Images and materials. I further acknowledge that there is no guarantee that any or all the participants’ Images will be used in any released media. I have been informed that this authorization is voluntary and is subject to revocation at any time, except to the extent that action has been taken in reliance thereon. I hereby represent that I am an adult and that I, on behalf of myself, my child(ren) and any and all persons or entities claiming by, or under me or my child(ren), release and forever discharge the organization, including without limitation all corporate affiliates and officers, directors, trustees, donors, employees, agents and volunteers, from any judgement, losses, liabilities, demands, damages, costs, and expense arising out of or incurred in connection with any claims, actions, suits, or other proceedings, in law or equity, in tort or contract, whether foreseen or unforeseen, accrued or unaccrued, known or unknown, arising from or incurred in connection with this release or the organization’s use of our likeness, photographs, videos, quotes, and/or summaries. I agree and give consent.Terms and ConditionsI certify that the information provided in the application is true and complete to the best of my knowledge. I authorize the investigation of all statements contained herein and give permission for my references to provide any information concerning my previous employment or other pertinent details. I release all parties from liability for any damages that may result from furnishing such information. I agree to terms & conditions. Δ