2018-19 NCSD Adult Ed Registration Form
Please take a moment to complete this form. If you have any questions, please contact us at 775-751-6822.
email address *
Your answer
Last name *
Your answer
First name
Your answer
Middle name *
Your answer
Maiden name *
Your answer
Gender *
Birthday (month, day, year) *
Your answer
Current phone number *
Your answer
Address (number, street, city, state, zipcode) *
Your answer
Birth place (city, state) *
Your answer
Name of emergency contact
Your answer
Relationship of emergency contact *
Your answer
Phone number for emergency contact *
Your answer
Last year you attended school
Your answer
Name of last high school *
Your answer
City and state of last school attended *
Your answer
Have you ever received special education services? *
Do you have a current 504 Plan? *
Ethnic group
As required by federal law, the Nye County School District must report student-related data by ethnic group. It is also a federal requirement that each district survey students to collect this information. Please complete this portion. Questions about this collection, or reporting of data by ethnicity, may be directed to the principal's office. Please answer both question 1 and 2.
Are you Hispanic/Latino *
What is your race? *
Authorization to release school transcripts
I certify that I do nave have a high school diploma, and it is my intention to enroll in the adult high school diploma program to earn credit toward a high school diploma, or to work toward my high school equivalency. To the best of my knowledge, the above information is true and correct, and I hereby authorize the release of my previous school records/HSE scores to the Nye County Adult Education Program, 2000 S. Mt. Charleston West, Pahrump, NV 89048 or FAX to: 775-751-6829.
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I am completing this application: *
By typing my full name below, it serves as my signature. *
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