GED APPLICATION PACKET

GED APPLICATION PACKET

for Haney Technical College
Have you ever attended Haney Technical before?*

YesNo
Name*

Last NameFirst Name
Former or maiden name

Last NameFirst Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Ethnicity: Are you Hispanic or Latino?*

YesNo
Race (Select one or more of the following)*

American Indian or Aslaskan NativeAsianBlackNative Hawaiian/Other Pacific IslanderWhite/Caucasian
Disability:*

I am disabled and may need accommodationsI am disabled and not requesting nor requiring accommodationsNot applicable/not self-identified
Citizenship:*

U.S. CitizenNon-Resident AlienPermanent Resident Alien
Education and Training - Highest school grade completed (select one):*

No school grades completed (ZZ)Completed 12th grade, did not attain diploma or equivalency (12)Earned high school diploma (D1)Earned high school equivalency (GED) (G1)Have disability and attained Certificate of Attendance/Completion (15)Completed some college (16)Earned a Career Certificate (17)Earned an Associate in Applied Sciences degree (18)Earned an Associate of Science degree (19)Earned an Associate of Arts degree (20)Earned a Bachelor’s Degree (21)Attained beyond a Bachelor’s Degree (22)Completed at least part of 1st -11th grade:
Highest grade completed*
Where this level was achieved?*

U.S. based schoolNon-U.S. based school
Street Address*
Include apartment, suite, unit, etc.
City*
State*
Zipcode*
County*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
EMERGENCY CONTACTS:
Completion is required for all students. If you are under 18, parent or guardian information must be included.
1. Contact 1 Last Name*
Contact 1 First Name*
Relation*
Phone Number*
2. Contact 2 Last Name
Contact 2 First Name
Relation
Phone Number
Any medical diagnosis?*

YesNo
If yes, what diagnosis?
Student Acknowledgement
I pledge on my honor that I will neither give nor receive any unauthorized assistance on my assignments/ examinations.

I understand that plagiarism of any kind could result in a failing grade and/or dismissal from the program.

I understand I must adhere to all the policies contained within the HTC handbook located on the haney.edu website.

I hereby give permission for HTC to release my record information for education, accreditation, and/or employment purposes. I understand the parking lot and all other areas of the campus are Bay District School’s property. Students should drive with caution when on or near campus, obeying all speed limits and other traffic laws. The speed limit in the parking lot is five (5) miles per hour.

I understand students are to park in the designated parking area(s) only. Students who park in unauthorized areas may lose the privilege of parking on campus and/or the vehicle may be towed.

I understand Students may not loiter around vehicles in the parking area(s). Students shall not occupy vehicles during class, between classes, or before or after school, except as they arrive and leave for the school day.

I understand Students may not smoke in their vehicles while on school property.
Vehicles on campus are subject to search by authorized personnel, including law enforcement canine units on routine campus visits, upon reasonable suspicion that the vehicle may contain illegal substances or weapons (i.e., alcohol, drugs, and/or weapons of any kind).

I understand students must have a parking permit/decal. This will be used to help locate vehicle owners in case the need arises. This also will be helpful if a vehicle has the lights on, is leaking fluid, or is involved in a minor accident with another vehicle when the owner is not present.

I understand the parking decal is to be displayed on/in the vehicle while parked on campus.
Military Status: (select one)*

No Military HistoryActive DutyEligible DependentVeteran (Service Dates Unknown)Active Member of the National GuardActive Member of the ReservesVeteran (Service Prior to 9/11/2001)Veteran (Service on or after 9/11/2001)Unknown/No Response
Employment Status: (select one)*

EmployedNot in Labor Force, incarcerated or not eligible for employment (N)Employed but with Notice of Termination or in transition Out of military service (S)Unemployed, looking and eligible for employment (U)
Single Parent/Single Pregnant Woman: (select one)*

Does not applySingle ParentSingle parent and single pregnant womanSingle pregnant woman
Displaced Homemaker: (select one)*

Does not applyUnemployed, cared for home/family, unpaid (A)Previously supported by public assistance or relative, no longer supported (B)Parent of child within 2 years of no longer receiving TANF (C)Unemployed dependent spouse of a member of the Armed Forces on active duty (D)
Are there any barriers that prevent you from being employed? examples: religion, language, etc*

YesNo
Disclosure (Ex-Offender):
Have you ever been charged with a violation of the law, misdemeanor and/or felony (even if adjudication was withheld) which resulted in, or, if still pending could result in, probation, community service, restitution, a jail sentence or the revocation or suspension of your driver license? (You are not required to include traffic violations which only resulted in a fine).*

Yes(E)No (N)
Homeless: (check only one)*

Lacks a fixed, regular, and adequate nighttime residence (A)Primary residence is a public or private place not designed for regular sleeping accommodation (B)Child of migrants who changed schools in last 3 years due to parents’ seasonal employment (C)Under 18 and Absent from Legal Residence (D)None of the above apply (N)
Migrant and Seasonal Farmworker: (check only one)*

Migrant (moves around in order to find employment, in particular seasonal or temporary work) (A)Seasonal farmworker (employed in temporary farmwork but do not move from your permanent residence to seek farmwork)(B)None of the above apply (N)
Income Status: (select all that apply)*

I will exhaust my TANF within 2 years of starting at Haney. (A)I will be unemployed for 27 or more weeks when I start at Haney. (B)I identify as being low income at the time of starting at Haney. (C)None of the above apply (N)
Liability Waiver
1. The student agrees that leaving his or her property on the campus of Tom P. Haney Technical College is voluntary. Additionally, the student
- agrees to assume any risk that is associated with leaving personal property, including but not limited to automobiles, boats, motors, tools, trailers, parts, and supplies, or other
- releases Tom P. Haney Technical College, including all employees and staff, and Bay District Schools, including all employees and staff, from any and all claims of damage and/or loss that may occur as a result of leaving personal property at Tom P. Haney Technical College.
2. The release is without limitation and includes the personal injury fees, attorney’s fees and any other losses that might occur to the customer or student.

3. The student agrees to hold Tom P. Haney Technical College and Bay District Schools, including all employees and agents, harmless against all claims of damage and loss including damage to Tom P. Haney Technical College property caused by the customer or student.
4. The student hereby warrants that he or she is physically fit and able to participate in activities at Tom P. Haney Technical College without any undue risk.

5.Tom P. Haney Technical College maintains the right to refuse participation in any activity if the school foresees that participation would risk damage to any party.

6.The student agrees that this waiver agreement shall remain in full force and take effect without change and that participation in all school based activities is pursuit to the terms of the agreement.
Permissions
I hereby grant permission to be given to access the Internet on campus.*

Yes(E)No (N)
I hereby grant permission to participate in activities where my image orlikeness may be electronically recorded on our ITV. (audio, video, and still photograph)*

Yes(E)No (N)
I hereby grant permission to participate in activities where my image orlikeness may be electronically recorded on our School/District Website. (audio, video, and still photograph)*

Yes(E)No (N)
I hereby grant permission to participate in activities where my image orlikeness may be electronically recorded on our School/District social media. (audio, video, and still photograph)*

Yes(E)No (N)
I hereby grant permission to participate in activities where my image orlikeness may be electronically recorded on local newspapers/television stations. (audio, video, and still photograph)*

Yes(E)No (N)
REFUND POLICY
Drop/Add period is considered the first 3 days of each semester. Tuition costs only will be refunded within this 3 day drop/add period. There will be no refund after 3 days. Tuition only will be refunded for No Shows.
ATTENDANCE POLICY
(THERE ARE NO EXCUSED ABSENCES or LEAVE OF ABSENCES ALLOWED)
* All students registered in class are expected to attend.

* Students must sign-in/out of class daily using the attendance kiosk.

* FOCUS will be the final authority in determining the attendance and absences for each student.

* It is the responsibility of the student to know the attendance policy.

* It is the responsibility of the student to be aware of all absences and keep up with them.

*Students will be dropped after 6 consecutive days absent from class.

* Students, who are dropped during the semester (Aug or Jan), cannot re-enroll until the beginning of the next semester.

* Students who do not attend the 1st three days will be considered a NO SHOW and be withdrawn.

* In the event of the need for extended leave, students must withdraw from Haney. There is no Leave of Absence for ABE/GED/ESOL students.

My signature below signifies that I have read and understand all aspects of this agreement.
I have read the above statements and agree to comply with all Haney policies.
Signature*

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Date*

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Date
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GED APPLICATION PACKET

EMERGENCY CONTACTS:

Student Acknowledgement

Disclosure (Ex-Offender):

Liability Waiver

Permissions

REFUND POLICY

ATTENDANCE POLICY

(THERE ARE NO EXCUSED ABSENCES or LEAVE OF ABSENCES ALLOWED)

I have read the above statements and agree to comply with all Haney policies.