EmailMe Form - FY26 STUDENT ENROLLMENT FORM

Last Name (Family Name): *
First Name (Given Name): *
I am interested in: *
English Language Classes
High School Equivalency Classes (GED/HiSET)
I would like to attend: *
Morning Classes
Night Classes
Before classes start you will need to attend a new student orientation. *
I can only attend a morning orientation.
I can only attend a night orientation.
I can attend either one.
Student Phone # *
### - ### - ####
Street Address *
City *
State *
Zip Code *
I have a social security number *
Yes
No
Social Security Number
Email *
Birthdate *
MM / DD / YYYY
Gender: *
Male
Female
Non-binary or other
No answer/prefer not to say
Emergency contact name
Emergency contact phone number
### - ### - ####
Are you Hispanic/Latino? *
No, not Hispanic/Latino
Yes, Hispanic/Latino
What is your race? (You may choose more than one.) *
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
What country were you born in? *
Native Language: *
How long have you been in the United States? *
Highest level of education completed: *
No schooling
Secondary School Equivalent (GED, HiSET, Home School)
Grades 1-5
Some Postsecondary Education, No Degree
Grades 6-8
Postsecondary or Professional Degree
Grades 9-12 (no diploma)
Unknown
Secondary School Diploma or alternate credential (High School Diploma)
Location of highest level of education: *
In U.S.
Outside U.S.
Job Status: (select one) *
Employed
Employed with separation notice
Unemployed (Not working but looking for a job)
Not in labor force (Not looking and not working)
Signature *
By signing above, I acknowledge that I am at least 17 years old and not enrolled in any K-12 public school or being home schooled. I certify that the information given on this application is true and accurate to the best of my knowledge. 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).
Today's Date: *
MM / DD / YYYY