Santa Rosa Adult School e-Learning Registration



-5715104775Santa Rosa Adult School e-Learning Registration 00Santa Rosa Adult School e-Learning Registration Revised 8/1/16center-4445This form must be filled out on your computer then printed, signed, and mailed or hand-delivered (we cannot accept faxed forms). Incomplete and/or hand printed registration forms will not be accepted. 00This form must be filled out on your computer then printed, signed, and mailed or hand-delivered (we cannot accept faxed forms). Incomplete and/or hand printed registration forms will not be accepted. Today’s Date FORMTEXT ????? Your email: FORMTEXT ????? 39116022225000Name FORMTEXT ?????324421566675* The school district requires the social security number in the student’s permanent records. For more information please refer to Florida Statute: 1008.386.020000* The school district requires the social security number in the student’s permanent records. For more information please refer to Florida Statute: 1008.386.Last, FirstMiddleMaiden54864041338500Social Security # FORMTEXT ????? Address FORMTEXT ????? Street City State Zip CountyDate of Birth FORMTEXT ????? Place of Birth FORMTEXT ????? Gender : FORMCHECKBOX Female FORMCHECKBOX Male -8953544818300027755855345339Program Enrollment Type (Select all that apply) ABE ASE/AHS/HSED ESL/ESOLInstitutional Programs: Correctional Facility Other Institutional Settings Community Correctional Program00Program Enrollment Type (Select all that apply) ABE ASE/AHS/HSED ESL/ESOLInstitutional Programs: Correctional Facility Other Institutional Settings Community Correctional Program052572560049734114484370Fee: $_______________________Receipt # ____________________ # ____________________Date: ________________________00Fee: $_______________________Receipt # ____________________ # ____________________Date: ________________________0153470400070729900-1460527631600689546544958000Phone: Home FORMTEXT ????? Cell FORMTEXT ????? Emergency FORMTEXT ?????ResidencyDo you live in a rural area (an area with a population of less than 2500 people)? FORMCHECKBOX Yes FORMCHECKBOX NoEthnicity: FORMCHECKBOX Latino or Hispanic OriginRace – Select all that apply: FORMCHECKBOX American Indian or Alaskan Native FORMCHECKBOX Asian FORMCHECKBOX Black or African American FORMCHECKBOX Native Hawaiian or other Pacific Islander FORMCHECKBOX WhiteAdult Level of SchoolingPART A: Highest School Grade Completed (select one): FORMCHECKBOX No school grades completed FORMCHECKBOX Completed one of the following school grades (mark the box next to the highest grade completed): 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX 7 FORMCHECKBOX 8 FORMCHECKBOX 9 FORMCHECKBOX 10 FORMCHECKBOX 11 FORMCHECKBOX FORMCHECKBOX Completed the 12th grade, but did not attain a diploma or equivalency FORMCHECKBOX Earned a high school diploma FORMCHECKBOX Earned a high school equivalency diploma (GED?) FORMCHECKBOX Have a disability and attained a special diploma or high school certificate of attendance/completion from completing an Individual Education Plan (IEP) FORMCHECKBOX Completed some college, but did not earn a certificate or degree FORMCHECKBOX Completed college and earned (check one): FORMCHECKBOX a Career Certificate FORMCHECKBOX an Associate of Applied Sciences degree FORMCHECKBOX an Associate of Science degree FORMCHECKBOX an Associate of Arts degree FORMCHECKBOX a Bachelor’s degree FORMCHECKBOX beyond a Bachelor’s degreePART B: Where was this level achieved? FORMCHECKBOX U.S. based school FORMCHECKBOX Not U.S. based schoolOFFICE USE ONLYAssessment – Pretest within first 12 hours of instructionAssessment name: ________________________ Date: ________________-6519062738000108800623570Enrollment Date: _______________________ Separation Date: _______________________00Enrollment Date: _______________________ Separation Date: _______________________5733415634909 Yes No020000 Yes No4626610555534Signed Release of Information on File: 020000Signed Release of Information on File: 2656931353060 Distance Learning00 Distance LearningCourse Title Attendance HoursTeacher____________________________________ _______________________________________________________ Revised 8/1/1610668023125400 COURSE SELECTION Online Courses Requested - Program/Course Title 1st FORMDROPDOWN 2nd FORMDROPDOWN 3rd FORMDROPDOWN -24130278257000379730669301400-24130131837400-2095512117100Employment Status (Select one – to be completed upon entry for each term/semester): FORMCHECKBOX Employed FORMCHECKBOX Not in Labor Force (incarcerated, not eligible for employment, or not seeking employment) FORMCHECKBOX Employed but have a Notice of Termination or in transition out of military service FORMCHECKBOX Not Employed (looking and eligible for employment)Information gathered pursuant to Florida Statute 1006.07 Duties to School Safety and DisciplineHave you ever been expelled from a public school? FORMCHECKBOX Yes FORMCHECKBOX NoHave you been subject to any stage of the criminal justice system? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been arrested and charged by the court or currently facing charges? FORMCHECKBOX Yes FORMCHECKBOX NoAre you returning to public school directly from a Juvenile Justice Program? FORMCHECKBOX Yes FORMCHECKBOX NoA “yes” answer to any of the above items requires completion of a full disclosure statement, which can be accessed by clicking here. This form must be completed, printed, and submitted with this application. Background (Select all that apply – to be completed upon entry for each term/semester):1. Do you have any reasons (attitudes, customs, practices, etc.) that keep you from being employed? FORMCHECKBOX Yes FORMCHECKBOX No2. Are you homeless and/or a runaway? FORMCHECKBOX Yes FORMCHECKBOX No If “yes,” please mark the choice that best applies to you: FORMCHECKBOX Lacks nighttime residence FORMCHECKBOX Has a normal nighttime residence FORMCHECKBOX Runaway (under the age of 18) FORMCHECKBOX Child of a migrant worker FORMCHECKBOX Living in a vehicle, travel trailer park or campground, abandoned building, or other substandard housing3. Are you currently a migrant or seasonal worker? FORMCHECKBOX Yes FORMCHECKBOX No If “yes,” please mark the choice that best applies to you: FORMCHECKBOX Agriculture or fish farming FORMCHECKBOX Traveling farmworker4. Military status – please mark “yes” or “no” for each of the three responses below: FORMCHECKBOX Yes FORMCHECKBOX No Active Duty Member of the uniformed services in your household FORMCHECKBOX Yes FORMCHECKBOX No Member or Veteran in your household who was medically discharged or retired for a period of one year or less FORMCHECKBOX Yes FORMCHECKBOX No Member of your household who has died on active duty or as a result of injuries sustained on active duty for a period of one year or less after death5. Are you a single parent? FORMCHECKBOX Yes FORMCHECKBOX No If “yes,” please mark the choice that best applies to you: FORMCHECKBOX Single, pregnant, and have at least one other child FORMCHECKBOX Single and have at least one child FORMCHECKBOX Single and pregnant (no other children) Revised 8/1/16390525207699400Please mark any of the items below if they apply to you: FORMCHECKBOX Receives Public Assistance FORMCHECKBOX Youth in Foster Care (including aged-out) FORMCHECKBOX Low-income individual (or their dependent) employed primarily in farming, but currently unemployed or finding difficulty obtaining work for at least 12 months out of the last two years FORMCHECKBOX Child of migrants who have changed school districts in the last 3 years due to parents’ seasonal employment FORMCHECKBOX Previously unemployed or underemployed while caring for home and family (unpaid) FORMCHECKBOX Previously supported by public assistance or family, and now unemployed or underemployed FORMCHECKBOX Parent of a child who has not received TANF benefits (formerly AFDC) in the past two years FORMCHECKBOX Unemployed dependent spouse of a member of the Armed Forces who is on active duty or is deceased or disabled as a result of military serviceThe Santa Rosa County School Board adheres to all equity compliance laws prohibiting discrimination and is committed to the policies and practice of non-discrimination on the basis of race, color, religion, gender, age, national or ethnic origin, marital status, disability or genetic identity. 228603120600Federal and state legislation requires the provision of accommodations for students with disabilities to meet individual needs and ensure equal access. Adult students with disabilities must self-identify and request such services. Please see a guidance counselor, teacher, or administrator concerning this.-52705-508000 FORMCHECKBOX I understand that in accordance with the Student Progression Plan for the Santa Rosa County District Schools, once I enroll in an adult education class, I may not return to a traditional Santa Rosa County high school. FORMCHECKBOX I certify that all information on this application is true and accurate to the best of my knowledge. Florida Statute 837.06: Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 776.083.Student signature __________________________________________________________________________ Date _____________-6477029083000RELEASE OF RECORDS AND TEST SCORES: FORMCHECKBOX Santa Rosa Adult School has my permission to share my academic records and test scores (including GED? scores) with teachers, administrative staff, and post-secondary institutions for educational purposes. FORMCHECKBOX Upon diploma completion, Santa Rosa Adult School has my permission to print my name in the graduation program and in local newspapers.-1524034997600-1524028946900Student signature __________________________________________________________________________ Date _____________e-Learning PolicyAfter reading the information below, click on each box to note that you understand these policies.All e-Learning students must: FORMCHECKBOX Complete all course work with 60% proficiency. No lessons may be omitted. FORMCHECKBOX Complete a minimum of two lessons per week. If there are 6 consecutive class days missed, the student will be withdrawn. The more lessons completed per week, the faster a course can be completed. FORMCHECKBOX Begin online classes within 10 days of registration. Applications will be invalid after this time. FORMCHECKBOX Do their own work. FORMCHECKBOX Take and pass a face-to-face midterm/final on each course in order to earn credit. Assessments are given at Santa Rosa Adult School in Milton. Additional sites may be available. A photo ID must be shown in order to prove accurate identification before testing. FORMCHECKBOX Schedule midterms/finals with their instructor. FORMCHECKBOX Follow district Code of Conduct when on campus.I have read and understand the above policies. Student signature __________________________________________________________________________ Date _____________ Revised 8/1/16Self Survey of Skills for Online LearningStudents who choose to participate in online courses need to examine their personal skills and aptitudes for taking a class online. The following attributes will greatly contribute to a student’s success: FORMCHECKBOX Yes FORMCHECKBOX NoSelf-motivation – Students can direct their own learning environment and methods to fulfill course requirements and achieve individual academic success. FORMCHECKBOX Yes FORMCHECKBOX NoIndependent learner – The online environment enables students to learn at their own pace, relieving the stress of feeling rushed or pressured and providing enjoyment in the learning process. FORMCHECKBOX Yes FORMCHECKBOX No Computer literate – Although it is not necessary to have advanced computer skills, students should possess a working knowledge of electronic e-mail, the Internet, as well as basic keyboarding skills.* You must have internet access and a valid e-mail address. FORMCHECKBOX Yes FORMCHECKBOX NoTime management – Students must be able to organize and plan their own best “time to learn.” There is no one best time for everyone, but the key to learning is to make the time to learn. FORMCHECKBOX Yes FORMCHECKBOX No Effective written communication skills – Students must use electronic e-mail and discussion forums to communicate with their peers as well as the instructors. The ability to write clearly to communicate ideas and complete assignments is essential. This method provides the learner with rapid feedback as well as means to inform instructors of any concerns or problems that they may be experiencing. FORMCHECKBOX Yes FORMCHECKBOX NoPersonal commitment- Because there are no bells that begin and end classes, students must have a strong desire to learn and achieve knowledge and skills via online courses. Making a commitment to learn in this manner is a very personal decision and requires a strong commitment to perform in order to achieve academic success. Overall, every individual who has the motivation and self-direction to take online courses will achieve success in our “any time, any place, any path, any pace” virtual environment. Meeting the needs of individual students is our top priority.I understand the above required skills for online learning and believe that I possess a sufficient number of these skills to successfully complete the online course for which I am registering.Student signature __________________________________________________________________________ Date _____________ ................
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