Adult Education Registration

Adult Education Registration Form
Program*
Level*
Are you interested in free computer training?*
Student Enrollment Information

This information is required to enroll you into our Adult Education Program.
Full Name*

First NameMiddle NameLast Name
Physical Address*

Estate/Street

Street Address

City/TownState/County

Zip Code
Phone Number*

Country CodePhone Number
Email Address*
Please enter an active email address.
Date of Birth*

DayMonthYear
Year of Last School Attendance*
Select year when you last attended school
Emergency Contact Information

Please complete this information for one emergency contact person
Full Name*

First NameMiddle NameLast Name
Phone Number*

Country CodePhone Number
Relationship*
Physical Address*

Estate/Street

Street Address

City/TownState/County

Zip Code
Highest Level of Education Completed*
Employment*
I accept to be enrolled as a student and consent to Elara Online Learning requesting copies of my identification documents for its official records.

I understand that I must become acquainted with the policies of Elara Online Learning, and in order to remain enrolled, I must be active online and in class, communicate with my instructors on a regular basis, take continuous assessment tests and end-of-semester exams, and fully comply with all institutional rules.

I agree to abide by the policies of the Elara Online Learning Program.
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Adult Education Registration Form