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Student Registration Form
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* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
Name (First and Last)
*
Your answer
Email address
*
Your answer
Mailing address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip code
*
Your answer
County
*
Your answer
Phone number (primary)
*
Your answer
Phone number (secondary)
Your answer
Are you over 16 and formally withdrawn from school?
*
No
Yes
Required
Do you have an F-1 Visa?
*
Yes
No
Required
Last grade completed?
*
Your answer
Did you graduate from high school or its equivalent?
*
Yes
No
Required
What are your goals for coming to this program?
*
To improve basic skills
To obtain a job
To retain or improve current job
To earn high school equivalence or seconday high school diploma
To enter postsecondary education or training
To decrease public assistance received
To obtain citizenship skills
To register to vote or to vote for the first time
ESL (for additional assistance please call 513-363-6100)
Other:
Required
Would you prefer
*
On-line
On-site
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