CIU 10 Adult Education Registration

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this registration form and a Student Support Coordinator will contact you ASAP to set up an appointment with you.

Email *

Full Name *

Full Address *

In which county do you reside? *

Centre County

Clearfield County

Clinton County

Best telephone number to contact you? *

Email Address

What is the best way to contact you to discuss the program and the classes we offer? *

Telephone at number listed above

Email at address listed above

Either is fine

Text at number listed above

Other:

What technology do you have available? Please check all that apply. *

Computer (PC/Laptop)

Internet (Hot Spot/Unlimited Data/High Speed)

Speakers (separate or in computer)

Web Cam (separate or in computer)

Microphone (separate or in computer)

Use cell phone for all technology

Required

What is your specific need in wanting to enroll in our classes? *

I need my Secondary High School Diploma (GED or HISET)

I need to sharpen my basic skills (Math and/or English)

I want to get into a post-secondary school and need to brush up on skills.

How did you find out about our program? *

Word of mouth

Newspaper Ad/Radio

My employer

PA CareerLink

Other:

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Central Intermediate Unit #10.

Does this form look suspicious? Report