Adult Basic Education Enrollment Form

Instructions You will be contacted by a member of the Adult Basic Education team once the application is submitted.

Today's Date

Last Name *

First Name *

Middle Name

Program you wish to enroll.

Adult Basic EducationPractical Nursing Prep Course

Have you attended another Adult Basic Eduction class before?

YesNo

If Yes, please give location.

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone (Primary) *

Phone (Alternate)

Age *

Date of Birth *

Gender

MaleFemalePrefer not to answer

Do you have a disability?

YesNo

If yes, do you need accommodations?

Email *

Last 4 of Social Security Number

Name *

Relationship *

Phone *

Are you Hispanic/Latino?

Note: The above question is about ethnicity-not race, please only choose one.No, not Hispanic/LatinoYes, Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or Spanish culture or organ, regardless of race.)

What is your race?

(you may select one or more of the following.)American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderCaucasian

Employment Status *Select one.

Do any of the following apply to you?

DHS Client/Public AssistanceHomelessState CorrectionsCounty or Community CorrectionsLiving in an institutional settingNone apply to me

Which of these barriers to employment apply to you?

Cultural BarriersLow Literacy LevelEnglish Language Learner

Do any of these other barriers apply to you?

Check all that apply.Single Parent or guardianDisabledMigrant WorkerLong-term UnemploymentExhausting TANF with two yearsHomelessDisplaced HomemakerEconomic DisadvantagedEx-offenderFoster Care YouthSeasonal FarmworkerNone of the Above

Highest degree or level of school completed

Please only check oneNo schoolingGrades 1-5Grades 6-8Grades 9-12 (no diploma)Grades 9-12 (high school diploma or alternate credential)Some college, no degreeCollege or professional degree

Was your schooling U.S.-based or Non U.S.-based?

U.S. BasedNon U.S. based

Statement of Non-Discrimination Southwest Technology Center does not discriminate on the basis of race, color, national origin, sex/gender, age, disability, or veteran status in admission to its programs, services, or activities, in access to them, in treatment of individuals, or in any aspect of their operations. Southwest Technology Center does not discriminate in its hiring or employment practices. This notice is provided as required by Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title IX of the Education Amendment of 1972, the Age Discrimination Act of 1975, and the Americans with Disabilities Act of 1990. Questions, complaints, or requests for additional information regarding these laws may be forwarded to Compliance Coordinators RaChel Crume and Kerry Evans 711 West Tamarack Road Altus, OK 73521 (580)477-2250 each weekday from 8:00 a.m. to noon and 1:00 p.m. to 4:00 p.m.

Adult Basic Education Enrollment

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