Application for Enrollment

 

First Name: Last Name:

Mailing Address:

What is your goal?:

E-Mail:

Home Phone: 

Work Phone:  

Cell Phone:    

Are you: Do you require childcare?

Do you have any special medical needs? If so please explain:

Who is your referral source?:

Drivers License Number:

Social Security Number:  

Date of Birth:

Will you need educational tuition assistance?

Ethnic Origin: Gender:

State of Official Residency:

If Alaskan Resident, For How Long?

Are you a U.S. Citizen?:

Were you ever in a branch of the military? If yes, which one and what job title?

Are you currently attending any school?:

If yes, state the name of the school: Highest grade completed?:

In the following box, please list as many schools possible that you have attended.  This includes any trade school, University orCollege, and GED.  Also, list the emphasis, and CITY/STATE including the dates you attended the schools if possible.  At the end of this list, you may also put down any certifications you may have earned.
Please list the name of the individual who you would want us to contact in the case of an emergency.  Please include the individual's name, phone number, and address if you can.

Do you understand that withholding information requested on this application or giving false information may make you ineligible for admission to the School or subject to dismissal?  With this in mind, do you certify that the above statements are correct and complete?  If admitted, do you agree to abide by the published policies, rules and regulations of Adult Learning Center?  Do you also further understand that from the time you file your application with the School, it is your responsibility to know all the rules, requirements and exemptions from my intended degree program?

Do you also authorize Adult Learning Center to release copies of your test scores, application information, transcripts and supporting documents to any agency for admission, financial assistance, or grants for Adult Learning Center to my parents, legal guardian, school district, or any state or federal agencies?  Do you also authorize Adult Learning Center to utilize biographical information or photographs for marketing purposes for school use only?