<p>MIS 4122 For Office Use Only REV 5/11 Data Base Cashier Receipt/Amount AS400 CHOICE TECHNICAL CENTER ADULT REGISTRATION FORM</p><p>Program Request Day Evening 1/2 3/4 FT</p><p>Today’s Date Social Security Number - -</p><p>Last First MI Name Name</p><p>Other Legal Name Used by Student (i.e. maiden name)</p><p>Street Address</p><p>City State Zip Code Phone Numbers Home Cell Work</p><p>Email Address</p><p>Male Female Birth Date (MM/DD/YY) / / Birth Place Emergency City & State or Country Contact Name Relationship Phone</p><p>Previous Education High School Graduate Yes Regular Diploma Special Diploma GED High School Graduate No Highest grade completed: 7 8 9 10 11 12</p><p>College Graduate Yes Which Degree AA AS BA/BS MA/MS College Graduate No Highest level completed: 1 2 3 4 5 6</p><p>Check all that apply: American Citizen Yes No Florida Resident Yes No Limited English Yes No Veteran W/Benefits Yes No Single Parent Yes No Single and Pregnant Yes No Single Parent and Pregnant Yes No Displaced Homemaker Yes No</p><p>Are you receiving assistance from any of the following? (Check all that apply) Jobs Plus Center Military Tuition Assistance Vocational Rehabilitation Department of Children and Families Pell Grant Florida Bright Futures Scholarship Florida Prepaid Tuition Other</p><p>(Go on to page 2)</p><p>MIS 4122 For Office Use Only REV 5/11 Data Base Cashier Receipt/Amount AS400</p><p>Please check the items that best describe your status:</p><p>Primary Ethnicity: Hispanic/ Latino American Indian/ Alaska Native Asian African American/ Black</p><p>Native Hawaiian/ Pacific Islander White Nonresident Alien Other</p><p>Marital Status Single Married Divorced Widowed</p><p>Employment Employed Unemployed and Available Unemployed and Unavailable</p><p>Have you ever been convicted of a felony? Yes No</p><p>Choice Technical Center provides aids and services for persons with disabilities. If you would like to declare a disability, please note your disability and the specific services you are requesting in the space below.</p><p>I understand that falsifying any information on this registration form could prevent my admittance to the school or result in my dismissal from school. I agree to comply with the policies, rules and regulations of both the Okaloosa County School District and this school. </p><p>Student Signature Date</p><p>REFUND POLICY: All refunds must be requested by the tenth instructional day of the year. All refunds will be made in full minus a $10.00 administrative fee. For more detailed refund information, please reference the Choice High School and Technical Center Handbook/Catalog. The Okaloosa County School District does not discriminate on the basis of race, color, natural origin, gender, religion, age, marital status, or disability for the purpose of recruiting, selection, treatment or termination of student.</p><p>Choice High School and Technical Center 1976 Lewis Turner Blvd., Fort Walton Beach, Fl. 32547 Phone 850-833-3500 Fax 850-833-3466 www.Okaloosa.k12.fl.us\choice</p>