2014-2015
Student ID #
(No escribe en esta sección)
Location
Day
School Board of Polk County
East Area Adult School
Student Application Form
Night
Teacher
Last Name (Apellido)
First Name
Social Security Number
Home Telephone Number (Teléfono) Cell Phone (Celular)
(
)
(
)
(# de Seguro social)
OFFICE USE ONLY
(Primer nombre)
Middle Name (Seg. nombre)
Former Name or AKA (Optional)
(Otro nombre)
E-Mail Address (Correo electrónico)
Address (House number and Street name) (Dirección fisica)
Apt Number City (Ciudad)
State (Estado)
Zip Code (Código postal)
Mailing Address (if different from above) (Direccion postal)
Apt Number City (Ciudad)
State (Estado)
Zip Code (Código postal)
Month (Mes) Day (Día)
Date of Birth (nac.)
Year (Año)
State (Estado)
(fecha
Birth de
Place
nac) City (Ciudad)
Country (País)
(Lugar de nacimiento)
Sex (Optional)
Race / Ethnic Origin (Optional) Check all that apply
Male (masculino)
American Indian (Indio Americano)
Female (femenina)
African American/Black(Afro-
Are you Hispanic or Latino? (Optional)
(¿Eres hispano o latino?) Please check one
Asian (Asiático)
Native Hawaiian (Hawaiiano)
Yes
americano)
White (Blanco)
No
(¿Tiene diploma o GED de los Estados Unidos?)
Graduation Status: Do you have a high school diploma or GED? Yes
No
Year________ School_____________________State_________
Current and Past Educational Enrollment Status
Yes
No
Last School attended____________________________Yr____City_____________________State_____________________
(Última escuela que asistio en su pais)
Are you a first time student in Adult or Career/Technical Education? Previous school________________________________________________State_______________
Yes
No
Have you ever attended East Area Adult School?
(¿Es la primera vez que estudia en una escuela de adultos?)
What year?________________Teacher/Site____________________________________________________________
(¿Ha estudiado antes en esta escuela?)
Yes
No
Have you ever been enrolled in any other Polk County School? Name of School________________________________________________________________________
Yes
No
Are you currently enrolled in another school or Home Education? Name of School ___________________________________________________________________________
(¿Ha estudiado en otra escuela en este condado?)
(¿Esta matriculado en otra escuela?)
NOTE: You must withdraw from your current school or Home Education before enrolling at East Area Adult School.
Language
Citizenship (Ciudadanía)
Is English your first Language?
Yes
(¿Es inglés su primer idioma? Si no, cual es?)
No
If No, what other language is spoken?
_________________________________
Employment Status
emergéncia)
(Nombre)
Name:___________________________________________________________
(Relacíon)
Relationship:______________________________________________________________
Home Number (
(Teléfonos)
)
Other Phone Number: (
)_______________________________________________
Personal Goal (Meta personal)
Employed (Trabajo)
Unemployed-available
(Sin trabajo, disponible)
Unemployed-unavailable
(Sin trabajo,no disponible)
(Optional)
Yes
No
U.S. Citizen
(Ciudadano de Estados Unidos)
Non-Resident Alien
(No residente)
Permanent Resident Alien
(Residente permanente)
Veteran (Veterano)
Emergency Contact: (En caso de
Employment (Empleo)
Obtain High School Diploma
Citizenship (Ciudadanía)
Improve Employment
Advance to Postsecondary Level
Improve Basic Skills
Retain Employment
Learn English (Aprender inglés)
Pass GED
Join Military
Has student ever had an arrest which resulted in a charge, or had any other Department of Juvenile Justice or Adult Department of Corrections
actions against him/her? If yes, give details , including name of probation officer if applicable. (¿ Ha sido arrestado alguna vez?)
The School Board of Polk County, Florida, prohibits any and all forms of discrimination and harassment based on race, color, sex, religion, national origin, marital status, age, homelessness, or disability or
other basis prohibited by law in any of its programs, services, activities or employment. To file concerns, you may contact the Office of Equity & Compliance, Human Resource Services at 863-534-0513. For
persons with disabilities needing services in the course of their studies, please contact your East Area Adult School Counselor.
_______________________________________________________________________
Signature of Student (Firma del estudiante)
Date (Fecha de hoy)
__________________________________________________________________________
Signature of Parent/Guardian of Minor Student ( Firma de padres si es menor)
Florida Statutes 837.06 provides that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be
guilty of a misdemeanor of the second degree.
Office Use Only: _____Photo ID ______Social Security Card
______Passport ______Birth Certificate ID Checked by___________
The Mission of Polk Public Schools: To ensure rigorous, relevant learning experiences that result in high achievement for our students.
Revised 5/12