New 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.

Adult Program of Interest

Last Name

First Name

Pronouns

Date of Birth

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Street Address

City, State

Zip Code

Neighborhood

Cell Phone

Email

Household Income

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

Race/Ethnicity

African American/Black

Asian American

European American/White

Latino/Hispanic

Middle Eastern or North African (MENA)

Native American/Alaska Native

Pacific Islander/Native Hawaiian

Multiracial

Other

choose not to respond

Primary Language Spoken at Home

Are you a person with a disability?

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

Education Attainment

Do you identify as LGBTQ+?

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

Were you born in the US?

Housing

Are you a veteran or active duty military?

Have you ever been arrested? (All of our adult students will be required to complete a criminal background check beginning with the July 2025 term. 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

Home Phone

Work Phone

Cell Phone

Email Address

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Alternate Contact

Alternate Contact Relationship

Alternate Contact Phone Number

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How did you find out about CHICAT?

Why do you want to be in this program?

Comments / Questions if any (Optional)

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Required