Enrollment Form - Adult Diploma Program
The Adult Diploma program is designed to help Ohio residents, at least 22 years of age, earn an Ohio adult high school diploma while simultaneously gaining training in an in-demand career field and industry credential(s).
Other/Last Name(s)/Maiden Name that may be listed on record(s):
Are you a U.S. Citizen?
County (Richland, Crawford, etc.):
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?
Are you currently employed?
Education History: Please check all that apply
Year student entered 9th grade:
Last academic year completed:
List the name of the last school you attended and the city/state.
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 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 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.
By submitting this form, you agree that the information provided within is accurate to the best of your knowledge.