Adult Ed Registration
Registration form
Last Name *
First Name *
MI
Street Address *
City *
State *
Zip *
County *
Home Phone
Cell Phone
Work Phone
Email
School District you currently live in
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Employment Status *
(Please check one)
Occupation
Career Objective: (How does this course effect your perspective occupation? *
Are you a present or previous student at Admiral Peary AVTS *
Yes
No
Present Student
Previous Student
Name of Class *
Required
Name of Class Term *
Race *
Please Check One
PA Department of Education information requests we ask the following questions below.  Please use these descriptions to answer them.
Disabled *
Yes
No
Are you Handicapped / Disabled?
Displaced Homemaker *
Yes
No
Are you a displaced Homemaker?
Economical Disadvantaged *
Yes
No
Are you economically Disadvantaged?
Educational Disadvantaged *
Yes
No
Are you educationally Disadvantaged?
LEP *
Yes
No
Are you Limited English Proficiency? (LEP)
Single Parent *
Yes
No
Are you a Single Parent?
Adult Education Policies:  Please read and initial below accepting the policies
Please initial accepting policies and submit registration *
Submit
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