ADOM-VCS: Adult Learning Registration
Spring II 2019 Session Dates: April 1 - May 18 (All students will need access to Chrome or Firefox browser)
Email address *
Last Name *
*You MUST use your full legal name (same as what is on your contract and/or Educator Certificate)*
Your answer
First Name *
*You MUST use your full legal name (same as what is on your contract and/or Educator Certificate)*
Your answer
Email Address *
THIS WILL BE YOUR USERNAME (course info, updates, etc.) - if you completed a virtual course via a previous session, you MUST use the same email address used in previous sessions (to keep track of all courses completed).
Your answer
Primary Phone Number *
Format: 555-555-5555
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Last 4 digits of Social Security Number *
Format: 1234
Your answer
School Name *
Type the entire school name
Your answer
School City *
Your answer
School State *
2 letter abbreviation (example: FL)
Your answer
Job Title/Position *
choose one
Religion *
Your answer
Course Selection - Course 1 *
Choose 1 course. Each course is $45. You may take two courses each session.
Course Selection - Course 2 *
Choose 1 course. Each course is $45. You may take two courses each session.
FACTS - Course Tuition *
Required
A copy of your responses will be emailed to the address you provided.
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