Community Learning Center - Intake Form
First Name
*
Last Name
*
Phone
*
Email
*
ZIP code
*
Age
*
School Status
*
Select
Currently Enrolled in School
Not Currently Enrolled in School - High School Graduate
Not Currently Enrolled in School - College Graduate
Not Currently Enrolled in School - Vocational/Technical School Graduate
Not Currently Enrolled in School - Other (please specify)
Pursuing High School Diploma/GED
Completed High School Diploma/GED
Pursuing College/University Degree
Completed College/University Degree
Vocational/Technical Training
Other (please specify)
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Name of the school where you are currently enrolled:
*
If "Other" was selected above please specify your situation below.
Do you have work experience?
*
Yes
No
How many years of work experience do you have?
*
Select
Less than 1 year
1-2 years
3-5 years
6-10 years
11-15 years
16-20 years
21-25 years
26-30 years
31-35 years
More than 35 years
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What technical skills are you interested in developing?
*
Digital Literacy
Software Development
Cybersecurity
Digital Marketing
Drones
3D Printing
Artificial Intelligence
Who referred you?
Select
Deborah T.
Dee M.
Sean'Jerrion C.
Elias B.
Adamari N.
Lucid
Melvin V.
Shannon R.
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terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
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