Southeastern Career Center Enrollment Form
Last Name *
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First Name *
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Mailing Address- Street *
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City *
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State *
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Zip *
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Email Address
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Male/Female *
Date of Birth *
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Social Security Number
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STN (Student Identification) *
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Home School *
Present Grade Level *
Home Phone
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Parent Cell
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Emergency Phone
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Parent/Guardian name *
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Choice of Program- 1st *
Choice of Program- 2nd *
Choice of Program- 3rd *
Parent Electronic Signature *
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Student Electronic Signature *
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Date *
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Time *
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