MTC Adult Ed 22-23 Application

Thank you for applying to the adult education programs at Fred K. Marchman Technical College.
Please Note: PAYMENT IS DUE AT THE TIME YOU SUBMIT THIS APPLICATION AND IS NON-REFUNDABLE.

Name of Person Completing Application*

First NameLast Name

Phone Number of Person Completing Application*

Please enter a valid phone number.

Are you over the age of 18?*

Yes, I am 18 or olderNo, I am not 18 or older

What is your preferred ESOL enrollment schedule **ALL ESOL CLASSES HAVE A WAITING LIST*

*Courses are offered based on availability. Due to increased demand for enrollment some courses / times may not be available at this time. If a course /time you require is full you will be placed on a wait list and notified when a seat opens.

What is your enrollment status?*

New/Never Enrolled at Fred K. Marchman Technical CollegePreviously Enrolled at Fred K. Marchman Technical College

Have you ever been enrolled in a Pasco County school?

If you have been enrolled in a Pasco County school not listed above, please write it in here:

What is your Pasco County school ID number - 6 digits (if applicable)

First Name*

Middle Name

Last Name*

Former or Maiden Name

If not applicable, please write N/A in the text field

Student's Date of Birth*

Date

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security Number*

Please format in the traditional social security number format

Gender*

MaleFemale

Birthplace: City*

Birthplace: State or Country*

Are you of Hispanic or Latino Ethnicity?*

YesNo

What is your race?*

Citizenship:*

Are you limited English proficient?*

YesNo

What is the primary language spoken at home?*

Are you a United States Veteran?*

YesNo

Employment status:*

EmployedUnemployed, Seeking EmploymentUnemployed, Not Seeking EmploymentEmployed, but received notice of termination of military separation

Have you been referred by an agency?*

What is the highest level of education you have completed?*

Highest school grade completed:*

Where was this level of education achieved?*

U.S based schoolNot U.S. based school

If you have a disability that you plan on disclosing, which of the following apply to you?*

All Adult General Education students who are requesting information concerning Adult 504 (ESE Accommodations) MUST contact MTC's Ms. Marlene Weinert. Contact information provided in the GED Workshop.

Parental Status:*

Single ParentSingle Pregnant WomanBoth - Single Parent and PregnantNot Applicable

Do any of the following apply to you as a Displaced Homemaker?*

Participant is providing service to family members in the home and is the dependent spouse of a member of the Armed Forces on active dutyParent whose youngest child will become ineligible (at age 16) to receive assistance under the program for Aid to Families with Dependent Children under Part A of the Title IV of the Social Security ActBeen dependent on public assistance or on the income of a relative but is no longer supported by such incomeWorked as an adult primarily without remuneration to care for home and familyNot Applicable

Have you previously been or are you currently now subject to any stage of the criminal justice process?*

Ex-OffenderNot Ex-Offender

Do you perceive any barriers with employment?*

No, I do not perceive hindrance to employmentYes, I do perceives hindrance to employment

Homelessness: Do any of the following conditions apply to you?*

Lack fixed, regular, and adequate nighttime residencePrimary nighttime residence not designed for human sleeping accommodationMigratory ChildUnder 18 and absent from legal residenceDo not meet any of these conditions

Migrant and Seasonal Farmworkers:*

MigrantSeasonal FarmworkerDo not meet either of these conditions

Military Status: Please select your military status:*

Income Status: Select the choice that applies to your income status at the entry to your program.*

Participant will exhaust Temporary Assistance for Needy Families (TANF) within two years of program entry.Participant has been unemployed for 27 or more weeks at time of program entry.Participant identifies as low income at program entry.None of the above applied to me at the entry of my program.

Please read the MTC STUDENT CODE OF CONDUCT

I understand that I must read and agree to the MTC student code of conduct (above) to finalize this application.*

I have read and agree to the MTC student code of conduct

I understand that smoking, vaping, and/or use of tobacco of any kind while on campus violates the F.K. MTC Student Code of Conduct and will subject me to removal from my program.*

I understand

Emergency Contact Notification

Pasco County Schools Adult Education Emergency Information
(Please fill in the fields below for information to be used in case of emergency)

Name of Emergency Contact #1*

First NameLast Name

Relationship of Emergency Contact #1*

Phone Type of Emergency Contact #1*

Phone Number of Emergency Contact #1*

Please enter a valid phone number.

Name of Emergency Contact #2 (optional)

First NameLast Name

Relationship of Emergency Contact #2

Phone Number of Emergency Contact #2

Please enter a valid phone number.

Phone Type of Emergency Contact #2

List any medications, health problems or allergies that the school should be aware of:

Family Educational Rights and Privacy Act (FERPA)

In accordance with the Family Educational Rights and Privacy Act (FERPA), an adult student’s educational records are confidential and can only be viewed and/or discussed with the student. Students may authorize MTC to discuss their educational records with another individual or agency by including them on a FERPA Release Form. They can obtain a FERPA Release Form in the Office of Adult Technical Education at any time after enrollment.

Adult students or the parent/guardian of minor students may inspect and review the records of that student in the presence of authorized personnel. Adult students or parent/guardians of minor students may request information in that student’s file be disclosed or released. The request must be in writing and shall include the following (State Board of Education Rule 6A-1.0955):

1. Must be signed and dated by the person making the request.
2. The records to be disclosed must be specifically identified.
3. Purpose of disclosure must be listed.
4. The party to whom the release is being made must be identified.
5. Each request for information to be released must be made separately.

In addition, the District may choose to publish and/or display this information in District sponsored publications, at various school or public functions, on the District’s local cable channel, website(s) and various social media channels, or in the school yearbook. While the intent of this practice is to be informative and celebratory, the District recognizes that concerns may arise regarding a student’s right to privacy.

Pursuant to the Federal Family Educational Rights and Privacy Act (FERPA), school districts are permitted to release "school directory information" unless applicants exercise their right of refusal. Under the FERPA law, this information could include: student name, residential address, e-mail address, phone numbers, photographs/images, school locations, field of study, degrees, honors and awards received and participation in athletics and other activities.

It is the intent and practice of the School District to publish, post, or release ONLY an applicant’s name,photograph, audio and/or video recording, displays of student work or other school-related information and ONLY as related to student achievement (e.g. academic/athletic recognition or award) or student accomplishment (e.g. a specially selected piece of work).

AUTHORIZATION FOR ACCESS TO MY EDUCATION RECORD (FERPA)

In accordance with the Family Educational Rights and Privacy Act (FERPA), I authorize MTC to release my education records to the following persons, agencies or organizations for the purpose of keeping such persons, agencies or organizations informed of my progress at Marchman Technical College:

If you do not want anyone to access your education records, please indicate that below, otherwise, complete the contact information (FERPA):

I do not want anyone to access my education records (FERPA)

Contact Information for FERPA

First NameLast Name

Relationship for FERPA Contact

Phone Number for FERPA Contact

Please enter a valid phone number.

I understand that by checking the box below. I am waiving my rights of nondisclosure of these records under federal law only to the persons or entities specifically listed. This release does not permit the disclosure of these records to any other persons or entities without my written consent or as permitted by law. This consent will remain in effect until revoked by me in writing.*

I have read and agree to the statement above.

RELEASE OF INFORMATION CONSENT FORM

• I authorize the release of my test scores (GED/TABE) to other parties such as adult education administrators, teachers, MIS staff, or other employees of the District School Board of Pasco County. This information is used for teaching and reporting purposes.

• I would like my GED scores added to my school records (transcript) and to be coded in the system as a graduate upon successfully passing the GED test.

Release of Information Consent form agreement*

I confirm that I have read and authorize the release of information consent form

NOTIFICATION OF INSPECTION FOR ASBESTOS CONTAINING MATERIALS IN PUBLIC SCHOOLS

NOTICE TO BUILDING OCCUPANTS AND PARENTS

The Environmental Protection Agency (EPA) has issued a final rule, 40 CFR Part 763, Asbestos Containing Material in schools, commonly referred to as AHERA. This rule requires all Local Education Agencies (LEA’s) to identify asbestos containing materials (ACM) in their school buildings and to take appropriate actions to control the release of asbestos fibers.

All inspections for Marchman Technical College have been completed and a Management Plan describing the results of the inspection and the action plan to control any asbestos found during the inspection, where applicable, has been submitted to the governor for approval. A copy of this plan is located in the administrative office of this school and at the Pasco County Schools Maintenance & Facility Services Department and is available for review upon request.

NOTIFICATION OF INSPECTION FOR ASBESTOS CONTAINING MATERIALS IN PUBLIC SCHOOLS*

I Have Read The Above Statement

PASCO COUNTY SCHOOLS MEDIA RELEASE FORM

Pasco County Schools (the District) strives to celebrate the accomplishments of its students by sharing information with the community. To do this, the District may submit press releases to local media (newspapers, radio, television, online news blogs) that include student names, student work,student photographs, and video and/or voice recordings.

In addition, the District may choose to publish and/or display this information in District sponsored publications, at various school or public functions, on the District’s local cable channel, website(s) and various social media channels, or in the school yearbook. While the intent of this practice is to be informative and celebratory, the District recognizes that concerns may arise regarding a student’s right to privacy.

Pursuant to the Federal Family Educational Rights and Privacy Act (FERPA), school districts are not permitted to release "school directory information" unless applicants exercise their right of refusal. Under the FERPA law, this information could include: student name, residential address, e-mail address, phone numbers, photographs/images, school locations, field of study, degrees, honors and awards received and participation in athletics and other activities.

It is the intent and practice of the School District to publish, post, or release ONLY an applicant’s name,photograph, audio and/or video recording, displays of student work or other school-related information and ONLY as related to student achievement (e.g. academic/athletic recognition or award) or student accomplishment (e.g. a specially selected piece of work).

I understand that if I do not wish to grant permission to Pasco County Schools to release my information as defined above I must complete a Media Release Form that must be completed by me, in person, at the administration office on campus.*

I have read and agree to these terms and conditions

Responsible Electronic Use Guidelines for Students

I have access to the Internet, school networks and electronic devices so I can…
expand my learning;
communicate with others about what I am learning;
research topics for class projects or for my personal learning;
create products highlighting my learning;
learn how to be a responsible and productive digital citizen.

Here are some things I need to know:
Electronic devices include but are not limited to computers, netbooks, iPads, iPods, tablets, cell phones, cameras, and other electronic devices that allow me to create and communicate.
I am responsible for all my online activities that take place through the network connection with my school’s devices or through access with my own personal electronic devices.

I am responsible for obeying all laws, including copyright. This also means I may not use the District logo or other District-owned content on my personal posts.

I do not have the right of privacy when accessing the Internet or network while at school.
Communicating electronically includes using my camera and cell phone to communicate visually.
When communicating electronically, I should ask myself: Is it safe? Is it kind? Is it respectful? Is it appropriate?

I do not have an absolute right to take, publish/post photographs or videos of others at school, as it may impact their individual rights of privacy.

Bullying or harassing someone either in person or electronically is wrong, violates the Code of Student Conduct, and is against the law.
Information I find on the Internet is not necessarily true or accurate.
There are filters to prevent access to inappropriate information, but no filter is perfect. I must protect myself by knowing how to close a window or click on the back button.

I can learn more about being a responsible digital citizen at http://www.safeflorida.net/safesurf.
Here’s what I agree to do as a responsible and productive digital citizen:

I will follow all school rules and laws when using electronic devices at school.

I will not damage equipment, upload harmful files, damage files, delete files, or access someone else’s files because it impacts others.

I will keep my password to myself and will not share it with others.

I will not search for or try to access obscene, harmful, or inappropriate material.

If I accidentally access inappropriate materials, I will close the window and tell a responsible adult.

I will not post or send hurtful, offensive or inappropriate material.

I will behave honestly, fairly, and with integrity when posting online, including my social networks.

I will follow rules of network etiquette, and I will be polite when communicating with others electronically. I will not use bad language or access messages from others who use bad language.

I will not post or share pictures of others without their knowledge and approval.

I will stay safe and will never meet or give out personal information such as my name, phone number, or address to someone I meet on the Internet without the express permission of my parents and/or teachers.

I will discuss my online activities with my parents so they understand how I am learning to be a good digital citizen.

My teachers and administrators have the right to access whatever I do online while in school if they are concerned about my safety or the safety of others.

I will not use others’ work without permission or without citing their work according to copyright laws.

If I’m not sure how to do something or whether something is okay to access or do, I will ask a responsible adult.

What happens if I violate this agreement and am not a responsible digital citizen?
Violations of this agreement will result in disciplinary action according to the Code of Student Conduct.

I have read The Terms and Conditions of the Responsible Electronic Use Guidelines for Students*

I Confirm That I Have Read And Agree To the Responsible Electronic Use Guidelines for Students

Disability Disclosure

Pasco County Schools (the District) hereby stipulates and affirms its policy of offering equal educational opportunities for all persons regardless of race, color, ethnicity, religion, national origin, age, gender, marital status, disability, genetic information or legally-protected characteristic. As such, it is the policy of the District to provide reasonable substitutions for any person enrolled in a postsecondary vocational programs who is hearing impaired, visually impaired, dyslexic or who has a specific learning disability where failure to meet the requirements is related to the disability. In order to receive disability accommodations or substitution, qualifying students must provide documentation that clearly shows evidence of a disability to the Special Populations Coordinator for individual consideration. The Special Populations Coordinator may be contacted at (727) 774-1731.

Confirm That You Have Read The Disability Disclosure*

I Have Read The Disability Disclosure

(TABE) The Test of Adult Basic Education is a diagnostic test that accurately predicts how adult students may perform on the GED Test. It is commonly used at MTC as a way of placing a student at the proper level in an adult basic education program. Before taking the TABE test you will need to complete a workshop

Please be advised, you must view online a workshop prior to enrollment.*

I have Read and Understand the above statement

Medical Emergency Care Treatment Authorization:
In case of accident or serious illness, I authorize the school to make whatever arrangements are necessary to provide care and treatment. I agree to pay all expenses incurred by the handling of this emergency care.

Medical Emergency Care Treatment Authorization Agreement*

I agree with the statement above.

Affidavit
I certify that the information on this application is correct to the best of my knowledge. By clicking the checkbox below I hereby agree to all the information provided and furthermore give my permission for the use of this data included herein in managing the program for which I am registered.

Affidavit Agreement*

I agree with the statement above.

Terms and Conditions

By submitting this Application, I hearby agree to pay the tuition fee of $31.20 for the school Term of which I am applying for. I further understand that at the start of each new Term the tuition fee required is to be re-submitted to secure my continued enrollment.

TERMS & CONDITIONS*

I Have Read And Understand The Above Terms And Conditions

NOTE: High school students must be formally withdrawn from their high school prior to submitting application.

I understand that application fees are non-refundable.*

I understand

APPLICATION FEES

English as a Second Language Tuition FeeTuition fees are non-refundable

$31.20

Total

$0.00

Credit Card Information
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

English as a Second Language Pasco Adult Education at Fred K. Marchman Technical College Application Spring 2022-2023