EmailMe Form - Student Enrollment Form-环球体育

Welcome to the Adult Education & Literacy program at St. Charles Community College! Because we are grant-funded, almost all classes are FREE!

Due to the Covid-19 pandemic, most instruction will be offered remotely. Completion of the registration form does not guarantee placement in a class. All students MUST be assessed prior to beginning class. This form must be completed and returned prior to the scheduling of your assessment. We will contact you after receipt of your enrollment form to let you know your next steps.

Requirements:
Must be at least 17 years of age
Cannot be enrolled in high school
Cannot hold an F1 (Student) Visa

As a recipient of state and federal funding, we are required to collect certain demographic information to meet reporting requirements. This information will not be used in a discriminatory manner. Please fill out the form completely.
Name *
First MI Last
Social Security Number (no dashes)
Ex: 123456789 *Encrypted for security.
I would like to enroll in: *
The English as a Second Language Program to learn English or improve my English skills for college or career readiness.
The Adult Basic Education Program to get my high school equivalency, improve basic academic skills and/or prepare for college readiness or career advancement.

I'm interested in these classes in the English as a Second Language program:

	Select All that Apply
Free ESL (English as a Second Language) classes
Advanced Writing
TOEFL Preparation
Pronunciation
Citizenship
Certified Nursing Assistant
Certified Kitchen Cook
Certified Logistics Assistant
Certified Logistics Technician
Microsoft Office Specialist

I'm interested in these classes in the Adult Basic Education program.

	Select All that Apply
Free High School Equivalency Preparation Classes
Free classes to improve basic academic skills for college readiness or career advancement
Focus Forward Developmental Math Classes
Certified Nursing Assistant
Certified Kitchen Cook
Certified Logistics Assistant
Certified Logistics Technician
Microsoft Office Specialist

Date of Birth *
MM / DD / YYYY
Gender *
Male
Female
Demographic Information
Are you Hispanic/Latino? *
Yes
No
Race (Choose all that apply. You must choose at least one.) *
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Highest Education Level Completed *
No Schooling
Grades 1-5
Grades 6-8
Grades 9-12 (No Diploma)
Secondary School Diploma (High School)
Secondary School Equivalent (GED/HiSET)
Some College/No Degree
College or Professional Degree
Location of Highest Education Level Completed *
U.S. Based Schooling
Non U.S. Based Schooling
Employment Status *
Employed
Unemployed
Employed with Separation Notice
Not in Labor Force
Barriers to Employment (Select at least one, but all that apply): *
Cultural Barriers
Disabled
Displaced Homemaker
Economic Disadvantage (<$25,000/yr)
English Language Learner
Ex-Offender (Probation & Parole)
Exhausting TANF within 2 years
Foster Care Youth
Homeless
Long-term unemployed
Low Literacy Levels
Migrant Farmworker
Seasonal Farmworker
Single Parent or Guardian
Specific Learning Disability (IEP)
Contact Information
Address *

Street Address City State / Province / Region Postal / Zip Code
Phone (Preferred Contact) *
### - ### - ####
Phone Type *
Home Phone
Cell Phone
Phone (Alternate Contact) *
### - ### - ####
Phone Type *
Home Phone
Cell Phone
Email *
Ex: yourname@email.com
Additional Information
Country of Birth *
Do you have an F-1 Visa? *
Yes
No
Students with an F-1 Visa are not eligible to enroll in our program.
Are you currently enrolled in high school? *
Yes
No
Students still enrolled in high school are not eligible to enroll in our program.
Are you a college credit student? *
Yes
No
Is anyone in your household receiving food stamps (SNAP) assistance? (This could qualify you for additional assistance.) *
Yes
No
With my signature below, I certify that the information given on this application is true and accurate to the best of my knowledge and belief. I consent to the release of my records maintained by a state or local education agency, including the information on this form and transcripts, grades, certificates, the High School Equivalency, and diplomas earned by me. This information may be used by the Missouri Department of Elementary and Secondary Education and shared with other state agencies for research and reporting purposes. Data shared between agencies includes, but is not limited to, employment, additional schooling, and follow-up services provided to you by agencies identified in the Workforce Innovation and Opportunity Act (2014).
Signature (Use mouse or finger to sign.) *
Clear

Demographic Information

Contact Information

Additional Information