EmailMe Form - 2025-2026 HSE Class Registration Form.

Select a class location: *
Eldon Eve - Monday & Wednesday - 4PM to 8:30PM
Fulton Day - Tuesday & Thursday - 9AM to 12PM
Jefferson City Day - Monday/Wednesday - 9AM to 1PM
Jefferson City Eve - Monday/Wednesday; Tuesday/Thursday - 6PM to 9PM
Versailles Eve - Tuesday & Thursday - 4PM to 8PM
AEL - Virtural - Online
Name: *
First Last
Social Security Number *
XXX-XX-XXXX
Birthday: *
MM / DD / YYYY
AGE: *
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone: *
### - ### - ####
Email: *
Preferred Method of Contact: *
Phone call
Email
Best time to call:
Morning
Afternoon
Evening
Program Type:
Adult Basic/Secondary Education
English Language Learner
Secondary Program: (select all that apply)
IELCE
Community Correctional
Correctional Facility
Other Institutional Setting
Workplace AEL Activities
Not Applicable
Gender: *
Female
Male
Hispanic? *
Yes
No
Race: *
American Indian or Alaskan
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Highest Level of Education: *
No Schooling
Grades 1-5
Grades 6-8
Grades 9-12
HS Diploma or Alt. Credential
High School Equivalency Certificate
Some Postsecondary, no diploma
Postsecondary/Professional Degree
Unknown
Labor Force: *
Employed
Unemployed
Not in the Labor Force
Employed (received notice of termination)
Location of Highest Level of Education: *
United States Based
Non U.S. Based
Barriers to Employment: (select all that apply) *
Cultural Barriers
Disabled Individual
Displaced Homemaker
Low Income
English Language Learner
Ex-Offender
Exhausting TANF within 2 years
Youth in Foster Care
Homeless
Long-term Unemployed ( 27 or more weeks)
Low Literacy Levels
Migrant Farmworker
Seasonal Farmworker
Single Parent/Guardian
Referred by: *
Community Action agency
Missouri Job Center
Employer
Vocational Rehabilitation
Probation and Parole
Family Services Division
Relative/Friend
Other
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). Currently, as of this date, I am not enrolled in a secondary school institution or receiving homeschool services.
Signature *
Clear
Date Time *
MM / DD / YYYY