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Student Registration Form- Adult Education
Please complete all of the information below. If you have any questions, please do not hesitate to reach out to our office at 810-591-4387 or 810-591-4380.
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Email
*
Your email
Last Name
*
Your answer
First Name
*
Your answer
Middle Name
*
Your answer
Maiden Name (if applicable)
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Last Grade Completed
*
Your answer
Street Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Cell Phone #
*
Your answer
Alternate Phone #
*
Your answer
Have you ever received Special Education services? (If yes, please provide a copy of your last IEP.)
*
Yes
No
Do you have a 504 Plan? (If yes, please provide a copy of your most recent plan.)
*
Yes
No
Ethnicity
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Hispanic or Latino
Not Hispanic or Latino
Race Information
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African American
Asian/Oriental
White
American Indian or Alaska Native
Native Hawaiian/Pacific Islander
Check all that apply
*
Drop out
Court Placed
Expelled
Other
Required
eSignature Agreement: By typing my name below, I acknowledge and certify that the information given is true and accurate. I understand it is my responsibility to inform the office if any of the above information changes.
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Your answer
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