Release Form for students under 21

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Richland One Adult Education would like to offer you the best possible educational experience with our program. In order to best serve you, we need to know some information about your past educational experiences. Please complete this survey and click submit when you finish.

What is your last name? *

What is your first name? *

What is your date of birth? *

YYYY

What is your email address? *

What is your phone #? *

What is the last school you attended? *

What is the last year you attended school? *

If you are under the age of 21 years, or turned 21 on or after September 1 of this school year, you may be eligible for educational services from Richland One Adult Education. Please check the following statements that apply to you *

I received special education services under an IEP (Individualized Education Plan) when I was last enrolled in public school.

I was served under a 504 plan when I was last enrolled in public school.

I was never served under an IEP or 504 plan.

Submit

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