First Name *

Last Name *

Phone *

Email *

Date of Birth *

Age *

How did you hear about us? *

Drivers License Number *

Do you have a High School Diploma or GED? *

High School Diploma

GED

Neither

Do you need assistance with getting your GED?

Yes

I have my diploma

Are you comfortable with hybrid online learning? *

Online

Campus

Are you in need of tuition assistance and scholarships? *

Yes

Are you receiving Government Benefits? SNAP, TANF, Medicaid, Homeless, or Foster Care Services? *

Please list all that apply

Do you have a criminal background? *

Please be specific of your charges we have service providers that will be able to assist you.

If you are working, what is your hourly pay rate? *

Do you have any children or expecting a child/ pregnant? *

Yes

We provide assistance with the mother and father of the child be sure to fill out separate applications

Do you have any disabilities? Examples: Depression, Anxiety, Difficulty with Focusing, ADD, ADHD, Vision, Hearing, Physical, etc. *

This will not prevent you from starting school. We have additional assistance programs.

We will need the following documents to properly screen you for the grant programs offered. Documents needed for registration: Drivers License, 2 forms of ID (Birth Certificate, Passport, Social Security Card) and Diploma (if available) *

If you do not currently have these documents please schedule an appointment to drop off documents.

Message

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By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.