Enroll Online - Career Programs

Enrollment Form - Career Programs
We're glad you're here! Please start the enrollment process by completing and submitting this form. If you have any questions, please call the Madison Adult Career Center office during business hours at 419-589-6363. We're here to help you get started on this journey.

Select a program









First Name:
Middle Initial:
Last Name:
Other/Last Name(s)/Maiden Name that may be listed on record(s):
Are you a U.S. Citizen?
Social Security Number:
Street Address:
Apt/Lot #:
City:
State:
Zip Code:
County (Richland, Crawford, etc.):
Primary Phone Number:
Work Phone Number:
Email Address:
Date of Birth:
Gender:

Do you have any felonies?
If you have a felony, indicate the month/year and explain:
Are you a veteran?
Parent serving Active Duty Military?
If applicable: What was your last Discharge date? What Branch of Service?
Are you Hispanic/Latino?
If not Hispanic, please check ethnic background below







Please check all that apply







Are you currently employed?
Current/Last employer:
Current/Last position:
Length of employment:
Rate per hour:
Check any/all issues below that may affect your academic performance and/or finding/keeping a job:








Education History: Please check all that apply





Name of your High School/G.E.D. Center:
City/State of your High School or G.E.D. Center:
Graduation Year:
Have you ever attended college/postsecondary education/other adult education program to pursue a certificate or degree?
If yes, provide the name(s) of ALL schools/colleges attended and dates of attendance (Month & Year - Month & Year)
How did you hear about Madison Adult Career Center? (Please check all that apply)












If applicable: Name of person/counselor who informed you about Madison Adult Career Center:
If applicable: Department of Job and Family Services/County One Stop Center (County):
Do you have any specific health conditions or disabilities, or take any special medications of which the school should be aware? Please answer YES or NO. If YES, please list all that apply
Emergency Contacts: Please list three contacts below in order of preference
Emergency Contact #1: Please list NAME, RELATIONSHIP and PHONE
Emergency Contact #2: Please list NAME, RELATIONSHIP and PHONE
Emergency Contact #3: Please list NAME, RELATIONSHIP and PHONE
Physician Contact Information: Please list PHYSICIAN NAME, CITY and PHONE (list up to two)
Preferred Hospital: Please list HOSPITAL NAME and LOCATION (list up to two)
Check YES if you agree to the following: I understand that my enrollment is voluntary and that I shall not hold the Madison Local School District, Board of Education or School Officials responsible for any injury resulting from my action or conduct. In the event of an emergency I give my permission for the school staff to contact an ambulance service and facilitate medical attention as necessary. (Madison Adult Career Center assumes no fiscal responsibility for the student if given treatment and/or admission to medical facilities.)
Student Certification: Please read the statements below and answer YES to indicate your understanding.
I certify the information given on this application is accurate and true to the best of my knowledge.
I understand that all tuition & fees are due at the beginning of the program. If I am receiving financial aid, funds will come directly to the school to be applied to my account. Credit balances will result in a refund.
I agree to follow all MACC policies and procedures as stated in the student catalog.
I understand that I must maintain satisfactory progress in my chosen training program (90% minimum cumulative attendance and a minimum 2.0 cumulative grade point average).
I understand that should I withdraw (or be dismissed from) a training program, I may be responsible for all tuition and fees based upon MACC’S refund policy. (Located in student catalog.)
I understand that failure to maintain satisfactory academic progress will result in probation or dismissal from my training program and loss of financial aid, which I must repay.
I authorize MACC to share my educational progress/financial aid information with any agency/employer which may be providing financial/other assistance or with a prospective employer. I will notify a staff member in writing if I do not want my information shared with a particular agency/employer.
I authorize agencies/employers/prospective employers to share employment/other related information with MACC.
I will share any sources of financial aid with the Financial Aid Administrator within 10 days of notification.
I authorize educational institutions to share academic/transcript information with MACC upon request.
Today's Date:
By submitting this form, you agree that the information provided within is accurate to the best of your knowledge.
Your Name:
Your Email:
captcha image

To validate your submission, please type the answer to the question.

© 2021. Madison Local School District. All Rights Reserved.
View text-based website