EmailMe Form - FY 24 STUDENT ENROLLMENT FORM

Last Name: *
First Name: *
I am interested in: *
English Language Classes
High School Equivalency Classes (HiSET)
Other _________________________
I would like to attend: *
Daytime Classes
Evening Classes
Before classes start you will need to attend a new student orientation. *
I can only attend a morning orientation.
I can only attend an evening orientation.
I can attend either one.
Phone # *
### - ### - ####
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
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? *
Do you have an F1 Visa (student visa)? *
No
Yes
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)
Barriers to Employment: (Select all that apply) *
Cultural Barriers
Disabled
Dislocated Worker
Displaced Homemaker
English Language Learner
Exhausting TANF within two years
Ex-Offender
Foster Care Youth
Homeless
Low Income
Low Literacy Levels
Long-term Unemployed
Migrant Farmworker
Minor with Adult Status
Public Assistance
Seasonal Farmworker
Single Parent or Guardian
Do you have children? *
Yes
No
How many children do you have? *
How old are your children?
Under age 1
1-2
3-4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Over age 18
In what district does your child attend school?
North Kansas City
Liberty
Park Hill
Platte City
Kansas City, MO
Kansas City, KS
Excelsior Springs
Independence
Smithville
Other _______________
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.
Signature *
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).
Date: *
MM / DD / YYYY