COTTAGE EDUCATION CORPORATION

A Not-for-Profit Educational Organization

15034 Old 441, Tavares FL 32778

(352) 742-7323 FAX 742-7325

Office Use only: Branch Name: _____________________ Program: ESL, LAUB. ABE, GED, SAT Group # 1-2 4 8 12 14

Please select the enrollment reason which best describes why you are taking this program

To enhance basic skills in order to pursue post-secondary education (Vo-tech-College)

To acquire entry level occupational skills necessary to obtain employment

C.E.C. pledges to teach any or all of the above stated programs to the applicant

STUDENT APPLICATION FORM

PERSONAL INFORMATION: Date ___/ ___/___

Name:____________________________________________________ __________M F

S. S.# _____ /______ / _____ Birth Date: ____ /____ /____ Phone ____/_____/_____

Address: _____________________________City:________________State:___Zip________

email Address _________________________________ Student ID#__________________

Home phone (___) _______/ ________/ Fax phone (___) _______/ ______

INFORMATION OF THE STUDENT EDUCATION

Last or current school grade level (Circle one):

Elem. 1 2 3 4 5 J.H. 6 7 8 H.S. 9 10 11 12 Col. 1 2

School attended: ___________________________________________ Date:___ /____ /_____

What do you hope to gain from this program? (Please write a complete sentence.)

_________________________________________________________ ___________________

I understand my participation in CEC programs is voluntary and I agree with the goals of the programs. CEC promises to provide individualized classes until my stated reasons for enrolling in the programs are fulfilled.

__________________________ ----------________________________

Signature of Applicant ---------------------------------------------Signature of parent/guardian