Adult Education Registration Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Use this online form to enroll in Adult Education classes at The Academy. Enrollment is based on available seats.

Course Name

Explanation of "Other" Program

First Name *

Middle Name *

Last Name *

Maiden Name (If applicable)

Social Security Number (The Academy requests social security numbers for the purpose of enrollment to verify your identity for official record keeping and state reporting. If you choose not to provide your social security number, financial aid may not be available to you. Please include your Social Security Number for State Reporting Purposes. Thank you!

SS#:

County *

Home Address/PO Box *

City *

State *

ZIP *

Cell Phone *

Home Phone *

Work Phone *

Birth Date *

YYYY

Gender *

Male

Female

Prefer not to say

Email Address

Race *

American Indian/Alaskan Native (Not Hispanic)

Black or African American (Not Hispanic)

Hispanic (any race)

White (Not Hispanic)

Multi-Racial (Not Hispanic)

Asian (Not Hispanic)

Native Hawaiian or other Pacific Islander (Not Hispanic)

Are You A Single Parent? *

Yes

Are You A Displaced Homemaker? *

Yes

Are You A Foster student? *

Yes

Are You Considered A Homeless Individual? *

Yes

Are You A Migrant as defined by the PA Department of Education? shorturl.at/gsvB1 *

Yes

Method of Payment - Academy staff will contact you to verify payment method(s) *

Self Pay

PA CareerLink (Workforce Investment & Opportunity Act funds)

Trade Act/NAFTA

OVR

Veterans Assistance

Student Loans/Aid

Employer Sponsored

Other:

Required

Please read and check that you understanding the following: *

I understand the following: Adult Short-Term Tuition. All registration fees must be paid in full before entering class. Tuition must be paid in accordance with the most current tuition payment schedule. Textbooks, equipment, and supplies may not be included in tuition. Any student being sponsored by a business, private industry, or funding agency (such as WIOA, Public Assistance Office, EARN, etc.) must present official written proof of funding approval before officially registering for a course. No student may enter class unless payment for registration fees and tuition is received prior to the first day of class or unless The Academy is given official permission to invoice a third-party, such as a funding agency, for the applicable fees. No refunds will be given after the start of class.

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Mifflin County School District. Report Abuse

Forms