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1
Which Adult Education location are your applying for?
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PHSC - Dade City
Marchman Technical College
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PHSC - Dade City
Marchman Technical College
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2
Please select your preferred class session.
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Monday to Friday 9:00 am to 12:00 pm
Monday and Wednesday from 5:00 pm to 8:00 pm
Tuesday and Thursday from 5:00 pm to 8:00 pm
Online (GED ONLY)
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Monday to Friday 9:00 am to 12:00 pm
Monday and Wednesday from 5:00 pm to 8:00 pm
Tuesday and Thursday from 5:00 pm to 8:00 pm
Online (GED ONLY)
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3
Please select your desired program.
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ESOL
GED
Online GED
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ESOL
GED
Online GED
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4
Student's Name
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First Name
Last Name
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5
Please enter your middle name, if applicable.
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6
Former or Maiden Name
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7
Address
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Street Address
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State / Province
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Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guatemala
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Guinea
Guinea-Bissau
Guyana
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8
Email Address
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9
Phone Number
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Please enter a valid phone number.
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10
Gender
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Male
Female
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11
Social Security Number
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If unknown or unavailable, enter 999-99-9999
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12
Date of Birth
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-
Date
Month
Day
Year
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13
What is your birthplace City, State/Country
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14
Are you a U.S. citizen?
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YES
NO
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15
Citizenship Authentication - Required for Enrollment
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Please upload
ONE OF THE FOLLOWING
documenting citizenship status:
US Passport, Permanent Resident Card (Green Card), US Birth Certificate, Certificate of Naturalization, Employment Authorization Document (EAD, FORM 1-766)
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16
What is your race?
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White
African American
Asian
American Indian/Alaska Native
American Indian
Pacific Islander
Multi/Other
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17
Are you of Hispanic or Latino ethnicity?
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YES
NO
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18
In order to enroll in adult education, you must
not
be enrolled in any secondary school, including home schooling. Are you currently withdrawn from school?
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YES
NO
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19
If you are a former Pasco County Student, enter your student number:
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20
Are you currently or has ever been an offender in the criminal justice process?
YES
NO
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21
What is the primary language spoken at home?
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22
Are you a displaced homemaker?
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A displaced homemaker is an individual who has spent years providing unpaid domestic services, and is currently experiencing the loss of financial support for those services.
YES
NO
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23
Are you a United States veteran?
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YES
NO
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24
Select applicable military status:
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Active Duty
Reserve/National Guard
Veteran/Retired
No Military History
Other
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25
What is your employment status?
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Employed
Unemployed
Seeking Employment
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26
Do you perceive any barriers to employment?
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YES
NO
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27
What is the highest level of education you have completed?
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Below grade 9
Grade 9 -12 (no diploma)
Some College
College Degree
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28
Do you have a disability that you would like to self-report? Please note that additional documentation may be requested for accommodations and support services.
*
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YES
NO
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29
Select your income status at the time of application:
*
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Will exhaust federal cash assistance (TANF) within 2 years of program entry.
Have been unemployed for 27 or more weeks.
Identifies as low income.
None of the above applies.
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30
The Family Educational Rights and Privacy Act (FERPA) is a federal law protecting the privacy of student education records. It applies to all educational institutions receiving U.S. Department of Education funding. It grants students the right to control the disclosure of their personal identifiable information.
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I have read and undertand my FERPA rights.
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31
FERPA RELEASE
In accordance with the Family Educational Rights and Privacy Act (FERPA), I authorize Pasco County Schools to disclose information from my educational records to the individual(s) listed below. Please indicate the person's name and phone number below.
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32
Enter name, relationship and phone number of emergency contacts:
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33
I understand that application fees are non-refundable.
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I understand
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34
Pasco County Schools Adult Education Tuition
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Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
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South Ossetia
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