Online Registration

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Please complete the following form: *

Returning Student

New Student

Select course you want to take: *

Which semester and time will you be attending: *

Personal Info:

Employment:

Employment Status: * Employed - Full Time
Employed - Part Time
Unemployed
Not looking for work
Unavailable for work
Retired
Employed with Separation Notice

Employer Name *

Work Address

City

State

Zip

Job position

Start date of employment *

Work Phone #

Parent/Guardian of (select all that apply) *

Child(ren) 5 years & younger	Child(ren) 6 to 10 years
Child(ren) 11 to 18 years	None

Education: *

Highest Educational Level/Degree Completed at Entry (Write in the grade level):
No schooling	Last grade completed
Some Post-Secondary, no degree	Post-Secondary or Prof. degree
Second School Equivalent	Secondary School Diploma or alternate credential

Last school attended and address:

School Name *

Address *

City *

State *

Zip *

Check one: * US based school Non-US based school

Disability: *

Self-disclosed
Visible
Visible & self-disclosed
None

Military Service Experience: *

Yes

Employment Barriers: * (select all that apply)

Educational goals/reasons for enrollment: * (select all that apply)

Please upload the mandatory documents below. If documents are not available at this time, you may upload them at a later time using the form found here. Documents must be received before the registration period ends on February 4, 2022.

Upload Photo ID:

Upload Proof of Residency:

Typing my name on this registration form affirms that I understand student information is confidential and will only be used for program administration, research and evaluation purposes.

e-Signature *

GED	Citizenship Preparation
Spanish GED	CDP (High School Credit Diploma Program)
ABE (Adult Basic Education Program)	ESL (English for Speakers of other Languages)

Cultural barriers	Disabled
Displaced Homemaker	English Language Learner
Ex-Offender	Foster Care Youth
Homeless	Long-term Unemployed
Low income	Low levels of literacy
Migrant Farmworker	Seasonal Farmworker
Exhausting TANF within 2 years	Single parent
None

To enter employment To keep/retain employment Court Order Required for Public Assistance Improve basic skills (ABE/ESOL) Earn a HS diploma Enter college or post-secondary training Progress toward HS diploma (GED, CDP) Not Applicable
Family and Community: * (select all that apply)
Increase involvement in children's education Participate in parent/child together (PACT) Participate in Parenting Education Earn Citizenship Use community Services Vote Not Applicable