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Interest Form - ALL PROGRAMS
Step
1
of
3
- General Information
33%
Name
*
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Middle
Last
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*
Street Address
Address Line 2
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Email Address
*
Phone Number
*
Cell Phone
*
Which program would you like additional information about?
*
Select One
AAPC Certified Professional Coder
Automotive Technician
Aviation Maintenance
CDL-A
Basic Welding
Certified Nursing Assistant
Cisco Academy/IT Professional
Civil Construction Laborer
CNA Train the Trainer
CPR & First Aid
Dental Assistant
Diesel Technician
Driver’s Education
Early Child Care
Electrical
Electrical Continuing Education
Electrical Trades
Electro-Mechanical Technician
Electronic Systems Technician
English As A Second Language (ESL)
English Learners in New Careers (ELiNC)
Frontline Supervision
GED® Prep Classes
Heavy Equipment Maintenance
Home Health Aide
HVAC/ Plumbing Maintenance
HVAC Continuing Education
HVAC Trades
Industrial Maint. Mechanic
Industrial Maintenance
In-school Credit
IT Professional
James H. Groves Adult High School
Medical Assistant
Medical Insurance Billing
Metal Fabrication/Welding
MIG/TIG Welding
Ophthalmic Assistant
OSHA 10 Hour – Construction
OSHA 10 Hour – General Industry
Phlebotomy Technician
Plumbing Trades
Practical Nursing
Outdoor Power Equipment
Supervisor Training (ELL)
Transportation & Logistics
Warehousing Operations & Forklift Training
Youth Apprenticeship Program
Are you currently employed?
*
Yes
No
Name of Employer
Last Date Attended School
*
MM slash DD slash YYYY
Name of Last School Attended
*
Have you passed any sections of the official GED® Exam?
*
Yes
No
Have you ever been enrolled in Adult Education or James H. Groves Classes?
*
Yes
No
If previously enrolled, where?
*
Do you have school aged children grades K-6?
*
Yes
No
Would they benefit from receiving free tutoring or homework help?
*
Yes
No
Referred By
*
Friend/Family
Social Media
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Agency/Social Service
Other
Have you ever been expelled, suspended pending a Superintendent’s hearing for expulsion, or withdrawn from school to avoid an expulsion from a public high school or other institution within the past 12 months?
*
Yes
No
Location of expulsion/suspension/withdrawal
*
Reason for your expulsion/suspension/withdrawal
*
Is there any other reason why you could not attend your regularly assigned high school?
*
Yes
No
Location you cannot attend
*
Reason you cannot attend
*
Do you have a high school diploma or GED®?
*
Yes
No
Have you ever been enrolled in a trades or career training program before?
*
Yes
No
If previously enrolled, which program were you enrolled in?
How did you hear about Polytech Adult Education?
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