* First Name

Middle Initial

* Last Name

* Mailing Address

* City

* State FL AK AL AR AZ CA CO CT DC DE GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

* Zip Code

County of Residence Hillsborough Pinellas Polk Pasco Hernando Other

Home Phone

Cell Phone

Parent Email Address

* Student ID Number

* Gender
Male
Female

* Birthdate

Permanent Address (if different from above):

City

State FL AK AL AR AZ CA CO CT DC DE GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

Zip Code

* Are you of Hispanic/Latino Origin?
Yes
No

* Race/Ethnicity - check all that apply:
American Indian
Asian
Black / African American
Hawaiian / Pacific Islander
White / Caucasian

Emergency Contact Name

Emergency Contact Phone

* Are you, your spouse, or your parent/legal guardian a law enforcement officer, firefighter or judge/justice?
Yes
No

How did you learn about the course? (check one)
Advertisement
Employer/Union
Court Order
Internet/Facebook
Friend/Relative
Teacher/Counselor
Drive By
Other

* Residency
Florida Resident
NOT a Florida Resident
In-State Evacuee
Out-of-State Evacuee

* Citizenship
U.S. Citizenship
Permanent Resident Alien
Non-Resident Alien

Citizenship Number

* What is your Highest Level (Grade) of Schooling COMPLETED last school year? Make a Selection Completed the 8th grade Completed the 9th grade Completed the 10th grade Completed the 11th grade

GED Year

High School Graduation Year

* Origin of Schooling
U.S. Based Schooling Non-U.S. Based Schooling

Address of Current School

* Is this your first time in Career Dual Enrollment?
Yes, this is the first time I have been a Career Dual-Enrolled Student
No, I have been a Career Dual-Enrolled Student previously

* Is English Your Primary or Native Language?
Yes, English is my Primary or Native language No, English is Not my Primary or Native language - I need assistance to read, understand, speak or write English

* Are you receiving assistance under the W.A.G.E.S. Act
Yes
No

* Have you ever been convicted of a felony?
Yes
No

* If yes, have your legal rights been restored?
Yes
No
Not Applicable

* What is your current military status? (check one)
No Military History
Eligible Dependent

* Employment
Employed
Employed but with Notice of Termination or in transition out of Military Service
Not Employed (looking and eligible for employment)
Not in Labor Force (not seeking employment, not eligible for employment, or incarcerated

* Single Parent (male or female with custody or joint custody of minor children
Yes
No

* Single Pregnant Woman
Yes
No
Not Applicable

* Income Status
Student Currently eligible to receive assistance from TANF (formerly AFDC) but will become ineligible within the next two years
Student unemployed for 27 or more consecutive weeks at time of program entry (this school year)
Student self-identifies as having a low income at the time of program entry (this school year) under any of the following:

• Student or member of immediate family receives benefits through SNAP/TANF, SSI, or other state public assistance
• Student is in foster care
• Total family income does not exceed the higher of the poverty line or 70% of the lower living standard income level
• Student has a disability and has personal income at or below the poverty line (regardless of family income)
• Student is a youth living in a high-poverty area

None of the Above

* Displaced Homemaker
Previously Unemployed or Underemployed while caring for home and family (unpaid)
Previously supported by public assistance or family and now unemployed or underemployed
Parent whose youngest child will become ineligible to receive assistance from TANF (formerly AFDC) with the next two years and who is unemployed or underemployed
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 service None of the Above

* Migrant / Seasonal Farmer Low-income individual (or their dependent) employed primarily in agriculture or fish farming for 12 months out of the last two years, currently unemployed or underemployed
Seasonal farmworker (or their dependent) whose agricultural labor requires travel such that the farmworker is unable to return to a permanent place of residence within the same day
Not Applicable

* Homeless Status
Not Homeless
Homeless with a fixed, regular nighttime residence
Homeless but staying in non-traditional housing (example: park, abandoned building, or bus station)
Migratory child who has changed school districts in the last 3 years due to a parent's seasonal employment

Other - check all that apply:
Perceived employment barrier(s) due to the student's attitudes, beliefs, customs, or practices
Previously or currently subject to any stage of the criminal justice process for committing a crime or delinquent act
Currently a patient or resident of a medical or special institution (but not incarcerated or homeless)

* Current High School

* Select a Dual Enrollment Training Program Make a Selection Cloud Computing and Virtualization Computer Systems and Information Technology Early Childhood Education Plumbing Veterinary Assisting Web Development

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Student Signature

Date

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