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GED Enrollment Form
Date
Student Name:
First Name *
Last Name *
Student Date of Birth:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Month
/
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
/
Year
Last Grade Level completed:
Student Gender
Male
Female
Other
Prefer Not to Answer
Student Ethnicity
American Indian or Alaskan Native
Asian / Pacific Islander
Black or African American
Hispanic
White / Caucasian
Multiple ethnicity/ Other
If multiple ethnicity/ Other, please specify
(IF “Hispanic or Latino/a” NOT selected in previous question) Are you of Hispanic or Latino/a origin?
Yes
No
Main/Physical Address:
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Mailing Address (If different than main/physical address):
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
Cell Phone:
Email:
Work Phone:
Phone to Call First in Case of an Emergency:
Information about what services you need:
cowwhnn3en5i
Do you REQUIRE a spanish speaking tutor?
Yes
No
Please share what you believe might be helpful to the tutor in working with you as a learner. Information provided will be confidential.
Describe what you need help with in more detail
List your strength(s)
List special interests and hobbies.
Please write anything else you would like to share that would be helpful.
Availabilities: We do our best to meet your Tutoring needs during the week. Please provide us with information on your availability for tutoring.
Day (s) of the week
check all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
Times
(We tutor Monday through Friday 9-5:30 with afterschool tutoring occurring usually at 3:30 and 4:30. Daytime tutoring occurs on the hour 9-3pm) Please indicate all times available.
Mornings any time
9:00 AM
10:00 AM
11:00 AM
Early Afternoon
Noon
1:00 PM
2:00 PM
After School
3:30 PM
4:30 PM
How many sessions of tutoring desired per week:
1
2
Other
Photograph and Video Release
I hereby grant the Estes Park Learning Place and its affiliates permission to use photographs, video and/or audio. These photographs, video and/or audio may be used without identification by name in future publicity and communications of the Estes Park Learning Place for an indefinite period of time.
Yes
No
By submitting this enrollment application, you agree to abide by the Tutoring Agreement.
Yes
By submitting this application you agree that The Estes Park Learning Place reserves the right to terminate tutoring if we believe it is not the right fit.
Yes
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