THE DO YOU ENRICHMENT CENTER

Name

Age

Date of Birth

Last school attended

Last grade completed

Address

Telephone number

Email address

Race:

American Indian/Alaskan Native
Black/African AMerican
Asian
White
Native Hawiian or other Pacific Islander

Employment Status

Employed Full-time
Employeed Part-time
Unemployeed and looking for work
Unemployeed and not looking for work
Unemployeed but unable to work due to a disability or incarceration

Other information: Click all that apply

On public assistance (include Welfare, SNAP, or Medicaid/Medicare)
Homeless
Displaced Homemaker
Disable
Dislocated Worker
Single Parent
In a Correctional Facility
Attended another Adult Education Program
18 years old and younger

Why are you enrolling in the STEP GED Program?

To improve my education
To attend college
To keep my job or to find a new one
To enlist in the military

Student Signature (first initial, lastname, 4 digit year you were born)