Southeastern Career Center Enrollment Form
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Last Name *
First Name *
Mailing Address- Street *
City *
State *
Zip *
Male/Female *
Date of Birth *
MM
/
DD
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YYYY
Social Security Number
STN (Student Identification)  
Current Grade Level *
Home Phone
Parent Cell
Emergency Phone
Email Address
Home School *
Parent/Guardian name *
Choice of Program- 1st *
Choice of Program- 2nd *
Choice of Program- 3rd *
Parent Electronic Signature *
Student Electronic Signature *
Date *
MM
/
DD
/
YYYY
Time *
Time
:
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