New ADULT ONLINE STUDENT APPLICATION

ADULT ONLINE STUDENT APPLICATION

Which course of study are you interested in:

(Choice does not guarantee enrollment)
Enrollment in any program is subject to availability and meeting certain eligibility requirements. CHICAT may cancel any of our classes if enrollment is not sufficient or for other reasons.

Adult Program of Interest

Today's Date:

Last Name

First Name

Middle Name

Pronouns

Birth Date

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Street Address

City, State

Zip Code

Household Income

Neighborhood

Cell Phone

Home Phone

Work Phone

DEMOGRAPHIC INFORMATION

Your response to the following Questions are very helpful because they allow us to demonstrate to our funders that we serve diverse populations and they help us prepare appropriate programming to meet the needs of diverse learners. However, you may select "choose not to respond" as your response.

Gender

Housing

Do you or anyone in your house hold receive goverment assistance?

If yes, indicate which services

Were you born in the US?

Primary Language Spoken at Home

Do you identify as LGBTQ+?

Are you a person with a disability?

Disability Description

Do you or did you have an IEP while in school?

Education Attainment

Did you or do you qualify for Free or Reduced Priced Meals while in school?

Are you a veteran or active duty military?

Have you ever been arrested? While a criminal background will not automatically exclude you from our programs, certain offenses will bar you from participation in our program.

EMERGENCY CONTACT INFORMATION

Contact Name

Relationship

Cell Phone

Home Phone

Work Phone

Email Address

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Alternate Contact

Alternate Contact Relationship

Alternate Contact Phone Number

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Are you or your Family Member Employed at CHICAT?

Yes No Not Selected

CHICAT Employee Family Member Name - Please put N/A if you answered no to the question above.

How did you find out about CHICAT?

Why do you want to be in this program?

Comments / Questions if any (Optional)

READ AND SIGN

My signature below indicates that I have read, understood, made correct, and completed statements on this application and any supplements to it. I understand that any omission or false statement made by me will result in disqualification, or discharge from program.

Student Signature:

Date

Enter the above code

Required