Class Pre-Registration
Full Name
*
First Name
Last Name
Parent/Guardian's Name (if under 18)
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
Date
*
E-mail
*
Home Phone Number
*
-
Area Code
Phone Number
Cell Phone Number
*
-
Area Code
Phone Number
When is the best time to call?
Mornings
Evenings
Weekends
How soon would you be interested in beginning your coursework?
-
Month
-
Day
Year
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G.E.D. Program
*
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Highest level of education
*
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Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10 Grade
11th Grade
12th Grade
Supply assistance
*
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Yes
No
Are you in need of school supplies need for you to complete this course such as notebooks, pens, binders etc.?
Enrollment Preference
*
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In- Person (6PM-9PM)
Transportation assistance
*
Select One
Yes
No
If you are in need of transportation, we are able to assist in transportation arrangements. *WE DO NOT PROVIDE TRANSPORTATION.
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