Adult Career Development Enrollment Form

First Name: *

Last Name: *

MI:

Mailing Address: *

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

Day (work/cell) Telephone: *

Night (home) Telephone: *

Email *

Gender (Male/Female) *

Last Four of Social Security Number *

Date of Birth (must be 16yrs or older): *

Course *

Certified Nursing AidCertified Medical AssistantCertified Medical Assistant UpdateHome Health DeemingPhlebotomyEmergency Medical TechnicianMotorcycle SafetyBasic WeldingAdvanced WeldingCLEET Combo I and IICLEET IIIOther

Education: *

Less than HS DegreeHS Graduate/ GEDSome college, no degreeTechnical DiplomaAssociates DegreeBachelors DegreeMasters DegreeDoctorate Degree

Race: *

American IndianAfrican AmericanHispanic or LatinoWhiteAsianPrefer to Not Answer

Please Check All *

I acknowledge that I must officially withdraw prior to the second class meeting for a refund. Refunds are tuition on minus $25.00 processing fee. If I withdraw before the course starts a full refund (tuition only) will be processed. Books are not refundable.I understand that if I am paying by check that if it is returned for any reason there is a bank fee added to the amount of the check. All returned checks plus the bank fee must be paid in cash.I understand that Southwest Technology Center will notify me if a class is cancelled or postponed at the above numbers(s).

Would you pay a higher tuition fee if a class enrollment is lower than require to cover the instructor cost so the class can still start as scheduled? *

The additional fee would be divided between the students enrolled.YesNo

Signature *

Today's Date *

Please Note:

NO CERTIFICATION WILL BE ISSUED FOR LESS THAN 75% ATTENDANCE IN CLASS!

Receipt Number:

Book Received

Amount Paid:

Payment Type

CheckCashCredit CardMoney Order

Payment Received By:

Self Pay or Reimbursement

Self PayCompany Pay or Reimbursed

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 Career Development Enrollment

FOR OFFICE USE ONLY

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