Center for Education, Career, and Workforce Development Registration Form
You may be required to sign additional paperwork such as photo releases, field trip permission slips, and emergency contact information.
Student Information
Student Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Current Age
*
Ethnicity
*
Please Select
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Decline to Respond
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Grade
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
N/A
Current School
*
GPA
Student ID
*
Last 4 SSN#
*
Training
Select the opportunities you are interested in your student participating in
*
C4C - Leadership Academy:
Youth Employment Services (Year-Round)
Life Skills: Empower 360 Resiliency Training
Y.E.S. Camp
Academic & Cultural Enrichment
List other areas of Interest
Select the Champions4Change Youth Leadership Program Experience(s) you are interested in:
Academic Reinforcement Test Prep ACT/SAT/CLT
Career, College, and Workforce Readiness
Select the Youth Employment Service(s) you are interested in:
Paid Internships
Externships and Apprenticeships
Select the Life Skills: Empower 360 Resiliency Training(s) you are interested in:
Family and Community Engagement
Civic Engagement
Emergency Contact
Parent/Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Relationship
*
Additional Information
How did you learn about this virtual course?
*
Facebook
Twitter
Instagram
YouTube
Search Engine
Online Ads
Friend/Family Referral
Other
Student Signature
*
Parent/Guardian Signature
Date Student Signed
*
-
Month
-
Day
Year
Date
Date Parent Signed
-
Month
-
Day
Year
Date
Print Form
Enroll Now
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