YEP Educates Enrollment Form
YEP Organization Wide Enrollment Form for YEP Educates outreach efforts
Today's Date *
Participant Information
First Name *
Last Name *
Preferred Name *
Which of the following class formats are you interested in? *
Required
Would you prefer to attend classes on the Westbank or Eastbank? *
What class schedule is best for your needs? *
Have you ever been in a YEP program? *
If so, which program?
How did you hear about YEP? *
Street Address *
City *
State *
Zip Code *
Social Security Number (type 000 if you prefer not to enter SSN here) *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Gender *
Primary Phone *
Cell Phone
Work Phone
Email Address
Ethnic/Racial Group (must answer both questions)
Are you, the participant, of Hispanic Origin? *
Race (check all that apply) *
Required
Parent, Guardian or Secondary Contact Information
Name
Relationship to participant
Address (if different)
City
State
Zipcode
Home Phone
Cell Phone
Work Phone
Email Address
Emergency Contact Information (if parent/guardian cannot be reached)
Name
Relationship to participant
Address (if different)
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
Email Address
Are you currently employed? *
If employed, who is your current employer? (If not, enter N/A) *
If employed, what is your occupation? (If not employed, enter N/A) *
Highest Grade Completed *
Thank you for applying to earn your high school equivalency diploma with YEP Educates! We will use the contact information you provided to reach out to schedule your program orientation. How would you prefer for YEP Educates staff to contact you? *
Required
If you are a referral partner completing this enrollment form with a client, please share your name, agency and contact number below -
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