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(* Indicates required field)

What Program do you want to Register for?
Adult High School DiplomaTechnical CertificateK-12 Program2 or More Programs

First Name *

Middle Initial

Last Name *

Parent or Guardians Full Name (If Enrolling Child)

Email to receive important information *

Best Contact Number *

Street Address *

APT / SUITE / UNIT

City *

State *

Zip Code *

The information requested in this secure form is required by the department of education

Students Date of Birth *

Students Place of Birth (City, State) *

Students SSN

Gender *
—Please choose an option—MaleFemaleOther

Race *
—Please choose an option—WhiteBlack or African AmericanHispanic or LatinoAmerican Indian and Alaska NativeAsianNative Hawaiian and Other Pacific IslanderTwo or more races

Last Grade Completed *
—Please choose an option—123456789101112Some CollegeDegree

Brief Description of Education History (Include Last School Attended, City and State) *

Do you require an IEP (individual education plan) or Special Learning? *
YesNo