High School Student Application for Continuing Education

Application

First: Required

Middle: Required

Last: Required

Gender: Required

Date of Birth: Required

SSN: Required

Citizenship: Required

Street: Required

City: Required

State: Required

Zip Code: Required

E-mail: Required

Home Phone: Required

Cell Phone: Required

Plan to Attend: Required

Year: Required

Course(s) Interested: Required

1. Are you Hispanic/Latino?

2. Regardless of your answer to the prior question, please select one or more of the following ethnicities that best describe you:

1 American Indian or Alaska Native (including all Original Peoples of the Americas)

2 Asian (including Indian subcontinent and Philippines)

3 Black or African American (including Africa and Caribbean)

4 Native Hawaiian or Other Pacific Islander (Original Peoples)

5 White (including Middle Eastern)

High School Name: Required

High School Address: Required

High School Principal: Required

Graduation Date: Required

mm/dd/yyyy

Parent/Guardian Information Required

Billing Name: Required

Billing Address: Required