JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
DISTANCE EDUCATION
Please complete this form if you are interested in our distance education program. All distance education students must be 21+ to participate. This program is only for individuals who do not have a high school diploma or equivalent.
Fill in the fields below and someone will contact you to schedule your orientation.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
FIRST NAME
*
Your answer
LAST NAME
*
Your answer
ARE YOU 21 OR OLDER?
*
Yes
No
DO YOU LIVE IN THE BUFFALO PUBLIC SCHOOL DISTRICT?
*
Yes
No
DATE OF BIRTH
*
MM
/
DD
/
YYYY
PHONE NUMBER (include area code)
*
Your answer
EMAIL
*
Your answer
ADDRESS
*
Your answer
CITY
*
Your answer
STATE
*
Your answer
ZIP CODE
*
Your answer
GENDER
*
Male
Female
Non-conforming/non-binary
DO YOU HAVE AT LEAST 6 HOURS EACH WEEK TO COMPLETE ASSIGNMENTS
*
Yes
No
ARE YOU ABLE TO ATTEND 3 HOURS OF TUTORING PER WEEK?
*
Yes
No
WHERE DID YOU HEAR ABOUT OUR PROGRAM?
*
Flyer
Social Media (Facebook, Instagram, Twitter)
Buffalo Employment and Training Center (BETC)
Other:
Thank you for your interest. Someone will contact you.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Buffalo Public Schools.
Report Abuse
Forms
