Registration Form, 1 and 3

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Email

example@example.com

Phone Number

Area Code Phone Number

Privacy Policy and Statement of Confidentiality

I understand that my information will be treated as confidential and used only for educational purposes. It will be seen only by education staff members who are required to treat all student information as private.

Signature

Clear

Today's Date

Date

Have you studied here before?

Yes No

How may we contact you? Check all that apply.

Phone call Text Email Postal mail

I have a high school diploma...

Yes No

Name of High School

I have a university or college degree or specialized training certificate...

Yes No

Name of university, college, or training school

Do you currently have access to an electronic device along with internet service?

Yes No No, I will need to complete my lessons electronically at the Center

Name of school you are currently enrolled in or attending?

I am working...

Part-time Full-time I am not working

Name of company or industry

How many hours (about) do you work per week?

Are you looking for work?

I am looking for work I am not looking for work I am retired

Emergency Contact: Who can we call for you in case of emergency?

Emergency contact name:

Emergency contact phone:

Area Code Phone Number

Are you currently working with any of the following Employment Security programs? (Check all that apply)

Wagner-Peyser Trade Adjustment Assistance Jobs for Veterans Unemployment Insurance TANF/NHEP

Are you currently working with any of the following Office of Workforce Opportunity programs?

WIOA Adult WIOA Youth/NH JAG/My Turn Dislocated Worker (Title I) SCSEP/National Able

Are you currently working with any of the following Department of Education programs?

Voc Rehab Career and Tech. Ed. Adult Education other than this center - please type name of program below:

Is there anyone you give us permission to communicate with about your education? If so, please list them below. This might be a case worker, child, counselor, or parent/guardian. Note: If you are under 18, we can speak with your school and parent/guardian.

Name of person(s) to communicate with about your education

Is there anything else we should know about you? (For example: medical issues, learning difficulties, classroom comfort needs, etc.) This question is optional.

Holy Cross Family Learning Center