Winter Pursuit Lab 2021 Pre-Registration Form

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Our Winter Workplace Readiness & Work-Based Learning Session (2 classes to choose from): Jan 11th - March. 18th, Monday-Thursday 1.5 hour a day 12:30-2:00pm Section C100 or a ONE hour a day, SAME dates/days but from 2:30-3:30pm Section C200, Early bird Registration to reserve a seat is Dec. 20th, and absolute Final Deadline for this form is January 1st! (If you still want to register after then please email pursuit@edcc.edu)

Email *

First Name (offical/legal) *

Last Name (offical/legal) *

Date of Birth (of student) *

YYYY

The student named above meets the following requirements for the provision of pre-employment transition services: 1. Is between 16 years of age and 21 years of age; 2. Has a documented disability (an IEP, a 504 eligibility, or a medically documented disability). *

Yes

No, student is older than 21 but has a documented disability IEP, 504, or medically diagnosed)

Phone Number (may add home, cell, and alternative) *

Emergency Contact Name & Phone Number (may add home, cell, and alternative) *

What time of day would work better for to take this class? *

2:30-3:30pm pm Monday-Thursday (This is more for returning students/higher functioning Ss with disabilities, includes Workplace Readiness Skills, Self advocacy, Group project and new curriculum)

Not this Winter from January - March of 2021, but we would be interested in the future (please keep me informed)

MAILING ADDRESS (INCLUDE CITY, STATE, AND ZIP CODE) *

STUDENT ID NUMBER & High school name if no longer in a high school, say which high school and when you graduated. *

GENDER *

Female

Male

Prefer not to say

Other:

Send me a copy of my responses.

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