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Campbell County Adult Education
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* Required
Student Information
Last Name
*
Your answer
First Name
*
Your answer
Middle Initial
Your answer
Preferred Method of Contact
*
Text
Phone call
Email
Any
Required
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Email
Your answer
Address
Street Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
County of Residence example Campbell County
*
Your answer
How did you hear about us?
select all that apply:
*
Billboards
Bus Signs
Corrections
Direct Mail
Employer
Facebook
GED Website
Instagram
My GED Account
Print (Flyer, Newspaper, etc.)
Radio
Referral from other agency
Search Engine (Google, Bing, etc.)
Signage or Road Sign
Snap Chat
TikTok
TV
Twitter
Word of Mouth
Required
Education
Last Grade Completed
*
Choose
1
2
3
4
5
6
7
8
9
10
11
12
GED
High School Diploma
Other High School Equivalency
Some College
Associates Degree
Bachelors Degree
Masters Degree
Doctorate Degree
Check if degree was obtained outside of US
Yes
Years Out of School
*
Choose
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
Additional Student Information
Gender
*
Male
Female
Hispanic Orgin
*
Yes
No
Race (select all that apply)
*
American Indian/Alaskan Native
Asian
Black, or African-American
Native Hawaiian or Pacific Islander
White
Required
Select all that apply
U.S. Citizen
Veteran
Immigrant
Homeless
RELEASE OF INFORMATION ( any/all that apply)
*
Kentucky Adult Education Recording System
Photo release for social media
KY Career Center
Ministerial Association
Prob. & Parole
Employer
DCBS/SNAP
Other:
Required
Currently Receiving
Unemployment Insurance
Disability SSI
Temporary Assistance for Needy Families (TANF)
SNAP
Medicaid
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