If you have been instructed to complete a registration form, you are in the right place. If you would like to enroll, please visit our Enrollment Link https://form.jotform.com/211814181464048, or click "Get Started" on our homepage www.projectlearnsummit.org
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Secure Registration Form
By filling out this form, you are registering for free classes at Project Learn of Summit County. If you are interested in learning about programming before registering, please visit our website at projectlearnsummit.org.
What brings you to Project Learn
*
I want to earn my High School Equivalence, or improve my reading and/or math skills.
I want to learn or improve my English. English is not my first language (ESOL).
Contact Information
Date
-
Month
-
Day
Year
Date
First Name
*
Last Name
*
Middle Initial
Maiden or other former name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
*
Phone Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Emergency Information
Contact Person
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Allergies/conditions we should know about:
*
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General Information
Age
*
* Students 16, 17, and 18 years old will need to provide documentation of official withdrawal or a copy of the diploma must be verified prior to enrollment.
Date of Birth
*
-
Month
-
Day
Year
Date
Country of Birth
*
Gender
*
Are you Hispanic/Latino?
*
Yes, Hispanic or Latino
No, not Hispanic or Latino
What is your race? Mark all that apply
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Are you a U.S. citizen?
*
Yes
No
If no, do you have an F-1 Visa
Yes
No
Are you a U.S. Veteran
*
Yes
No
Are you registered to vote?
*
Yes
No
Do you have a disability (physical, emotional, sensory or learning)?
*
Yes
No
If yes, please list needed accomodations.
Do you have a driver's license?
*
Yes
No
Do you have reliable transportation?
*
Yes
No
Do you have reliable childcare?
*
Yes
No
Not applicable
Number of children under 18 living in your home?
*
Are you a single custodial parent?
*
Yes
No
Do you receive public assistance?
*
Yes
No
If yes, mark all that apply.
TANF
SNAP (food stamps)
Other
What is your yearly household income?
Please Select
$0-$2,999
$3,000-$5,999
$6,000-$8,999
$9,000-$11,999
$12,000-$14,999
$15,000-$19,000
$20,000-$29,000
$30,000-$39,000
$40,000-$49,000
$50,000-$59,000
$60,000-$69,000
$70,000-$79,000
$80,000-$89,000
$90,000-$99,000
$100,000 or more
Last full grade completed
Please Select
No schooling
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade - no diploma
Secondary School Diploma or alternate credential
Unknown
Secondary School Equivalent
Some Postsecondary education, no degree
Postsecondary or professional degree
Employment Status MARK ONE
*
Employment, full-time
Employment, part-time
Employed; Notice of job termination/ military separation
Not employed, but look for a job
Not employed, not looking for a job
Retired
Name of last school attended
*
Location of last school attended
Please Select
US
Non-US
Did you graduate from high school or its equivalent?
*
Yes
No
What are your goals for coming to this program?
*
To improve basic skills
To improve English language skills (ESOL)
To obtain a job
To retain or improve current job
To earn high school equivalence or secondary school diploma
To enter postsecondary education or training
To decrease public assistance received
To obtain citizenship skills
To register to vote or to vote for the first time
Other
How did you find out about this program?
*
Employer
Family or Friend
I attended before
Newspaper/television/radio ad
Brochure/Flyer
Department of Job and Family Services/ OhioMeansJobs Center
Opportunities for Ohioans with Disabilities (OOD)
Court/corrections/probation officer
Internet - agency website, social media
Other
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English for Speakers of Other Languages (ESOL students only)
Complete this section if you are learning or improving your English language skills
Year you entered the country
Do you plan to stay in the U.S. permanently?
Yes
No
If no, how long do you plan to stay?
What is your native language?
What languages do you speak?
Have you studied English before?
Yes
No
If yes, how long?
What would you like to improve? Mark all that apply
Speaking
Listening
Reading
Writing
Knowledge of American culture
Do you want to prepare for the U.S. Citizenship Test?
Yes
No
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Student Status
Mark all that apply
*
Disabled
Low Income
Displaced homemaker
Dislocated worker
Homeless
Long-term unemployed
Youth in foster care
Migrant farmworker
Ex-offender
Exhausting TANF
None of the above
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