Campbell County Skills U Enrollment
* Required
Student Information
Last Name
*
Your answer
First Name
*
Your answer
Middle Initial
Your answer
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
*
Your answer
How did you hear about us?
select all that apply:
*
Facebook
Online Search (example MyGED.org)
Outdoor Signage
Print Advertising
Referral- Family and Friends
Referral- State Agency
Returning Student
School
Work
Other:
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
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45
46
47
48
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50
51
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54
55
Additional Student Information
Gender
*
Male
Female
Living Area
*
Rural (country or low population area)
Urban (cities, towns, or suburbs)
Hispanic Orgin
*
Yes
No
Race (select all that apply)
*
American Indian/Alaskan Native
Asian
Black, or African-American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White, not of Hispanic Origin
Required
Select all that apply
U.S. Citizen
Veteran
Immigrant
Homeless
Currently Receiving
Medicaid Wellcare will pay for GED
Medicaid Anthem BlueCross will pay for GED
Medicaid Aetna will pay $100 upon completion
Medicaid Humana, Passport
Unemployment Insurance
Temporary Assistance for Needy Families (TANF) will pay for GED
SNAP Client
Disability SSI
Other:
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