Please review the application before submitting to make sure you have completed all sections. Incomplete applications will not be accepted.

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* 1. Today's Date

Date

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* 2. Program Start Date:

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* 3. Do you plan to enroll in the complete program or partial program?

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* 4. First name:

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* 5. Middle Name: (Or N/A)

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* 6. Last Name:

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* 7. Other Names (Maiden):

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* 8. Last 4 Digits of Social Security Number:

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* 9. Date of Birth: (Month/Date/Year)

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* 10. Street Address:

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* 11. Apartment Number:

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* 12. City:

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* 13. State:

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* 14. Zip:

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* 15. Cell Phone:

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* 16. Other Phone:  (If no other phone, write N/A)

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* 17. E-Mail:

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* 18. Confirm E-mail:

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* 19. Do you have your high school diploma?

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* 20. If you do have your high school diploma, was it issued

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* 21. Have you previously attended college or a post-secondary school?

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* 22. If yes, where: 

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* 23. Please check all that apply:

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* 24. Please review your responses prior to clicking the submit button. Incomplete forms will not be processed.

Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and are the legally binding equivalent to my handwritten signature.

Electronic Signature (first and last name)

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* 25. Date: (Month/Date/Year)

We reserve the right to reschedule or cancel any course that does not meet our minimum enrollment requirements.  If a course is cancelled or rescheduled, all fees paid are subject to reimbursement or transference, upon presentation of a receipt.
The Columbus Board of Education does not discriminate based upon race, sex, sexual orientation, religion, color, national origin, age, gender identity or expression, ancestry, familial status, military status, disability, genetic information, or any other legally protected category (collectively, "protected classes") in its educational programs, activities, treatment of people and employment practices.

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