Register – ACCEL College & Career Readiness Program

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ACCEL Student Registration Form

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Name*
First Middle Last
I am enrolling in the following program:*
- ELL (English Language Learning) classes - I need to learn English.
- HSE (High School Equivalency) classes - I need a High School Equivalency
Which location are you interested in attending classes?*
- Carson City
- Fallon
- Fernley
- Online
Date of Birth*
Age*
Students ages 16 and 17 years old may enroll, but must provide a letter of withdrawal from the last school attended and signed, parental consent prior to enrollment.
Gender:*
- Male
- Female
- Other
Primary Language*
Ethnicity/Race*
Choose one or more.
- Amer. Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Pac. Islander
- White
- Hispanic/Latino
Highest Grade Level of School Completed:*
- Never attended school
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12 - No Diploma
- HSE (GED, HiSET)
- High School Diploma
- Some College
- College Degree or Professional Degree
Where?*
- U.S. Based Schooling
- Non U.S. Based Schooling
Are you employed?*
- Yes
- Not Looking for Work
- Looking for Work
How many hours do you work per week?*
Company Name*
Position*
How much do you make per hour?*

Student Profile*
Check all that apply.
- Cultural Barriers to Employment
- Disabled
- Displaced Homemaker
- Low Income
- Ex Offender
- Exhausting TANF
- Foster Care Youth
- Homeless
- Long Term Unemployed
- Migrant/Seasonal Farmworker
- Single Parent or Guardian
- None of the Above
Address*
Street Address City State ZIP Code
Mobile Phone*
Home Phone
Email*
Emergency Contact Name*
Emergency Contact Phone*
Emergency Contact Relationship
- Spouse
- Parent
- Sibling
- Relative
- Friend
- Son/Daughter
- Co-Worker
- Other
Social Security number or ITIN:
Your personal information is kept secure and is not shared or used for any other reason than to improve adult education programs. Your social security number helps us track your individual employment and wage record and compile required reports for our grants.
Which location are you interested in attending classes?*
- Carson City
- Fallon
- Fernley
- Online

Why are you Enrolling?
- Learn English
- Prepare for the GED or HiSET
- Prepare for College
- Train for a Career
What is your Career Path or Goal?*
Are you interested in any of the following career training programs?*
- Medical Billing and Coding
- Pharmacy Technician
- Hospitality, Food Service, and Customer Service
- Medical Assisting
- Paralegal
- I am not interested in career training at this time.
Code of Conduct*
I agree to the code of conduct.
ACCEL College and Career Readiness is a caring learning community which respects the right of each individual student to have a safe, enjoyable, and successful learning experience. As members of an extended college community at Western Nevada College, all students are reminded that we must abide by college policies and expectations, including those relating to: equality, diversity, health, and safety.
• Attendance: Students must attend class sessions regularly, exhibit good conduct, and complete all required class work. ACCEL is financed by federal funds based on student enrollment, participation, and completion of classes and programs. Therefore, students must agree to be in regular attendance to ensure continuation of the class. Attendance is required at the first class session or the student may be dropped. Classes with below ten students are subject to reduced hours or cancellation. Individual students may be dropped from the class due to low attendance.
• Children in class: Children are not permitted in class without prior authorization from the Director. Students are asked to make arrangements for childcare.
• Tobacco: Western Nevada College is a tobacco-free campus. All tobacco products including cigarettes, vapes, and chewing tobacco are prohibited anywhere on campus.
Consent Form*
I consent to the following.
1. Consent to the release of information from my student record for the purposes of statistical reports. I understand that this information is to assist the Nevada Department of Education in obtaining and reporting information concerning employment and education gains as required by federal legislation and regulations.

I understand that the student record includes my social security number, which may be shared by the Nevada Department of Education with any of the following entities:

• Nevada Department of Employment Training and Rehabilitation

• Nevada System of Higher Education

• An official High School Equivalency (HSE) scoring site

I understand that reports based on this information will contain statistics about follow-up measures for adult education students in Nevada, and that NO specific or personal information about me will appear in these reports.

2. I authorize the use of my image or likeness, and displayable work products by Western Nevada College on media including but not limited to, WNC website and
social media channels, bulletin boards, newsletters, and press releases.
I authorize the release of my records to the following people and/or agencies:
Type Your Name Verifying Your Agreement with the Above Statements.*
Student ID

ACCEL College & Career Readiness Program

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