Learning Center Enrollment form
2018-2019 School Year `
Student Name: *
Last, First, Middle Initial
Your answer
Student Email:
Your answer
Gender
Date of Birth: *
mm/dd/yyyy
Your answer
Street Address *
Your answer
City, State, Zip *
Your answer
Phone Number *
Primary
Your answer
Alternate phone number for you
Please provide another phone number where we may reach you during the day
Your answer
Emergency Contact *
Name of a relative or close friend we can also reach
Your answer
Emergency Contact Phone Number: *
Your answer
Are you Hispanic/Latino?
Race
In what language do you read/write?
Do you have a high school diploma? *
What year did or will your class graduate from high school? *
yyyy
Your answer
Have you ever taken college courses, including CNA/CMA?
Name of high school or learning center you last attended: *
Your answer
City in which the high school or learning center was located:
Your answer
Do you have any illness or learning difficulty which would interfere with learning?
If so, please explain.
Illness name or learning difficulty...along with special instructions:
Your answer
I agree to notify The Learning Center of any changes to any of my contact information: *
Please initial to signify you agree to this statement
Your answer
The electronic signature below and its related fields are treated by Hays Unified School District 489 like a handwritten signature on a paper form. *
I affirm all the information provided is true and correct to the best of my knowledge. Please initial if you agree your information is true and correct.
Your answer
Electonic Signature *
Type your name
Your answer
Signature Date:
MM
/
DD
/
YYYY
Office Use Only
Student PS #:
Your answer
Submit
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