Basic Education Classes and GED Preparation Home $ Basic Education Classes and GED Preparation Application Please enable JavaScript in your browser to complete this form.DateSocial Security NumberClass SiteTelephone NumberName *FirstMiddleLastDate of BirthAgeAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeGenderMaleFemaleMarital StatusSingleMarriedWidowedDivorcedEmployerSupervisorEmployer Phone NumberJob TitleScheduleDays and HoursAre there any health problems that could affect your performance or attendance?Emergency ContactEmergency Contact Phone NumberHighest Grade CompletedLast School AttendedIf the highest grade completed is 12th grade, which of the following apply to you? (select all that apply)High School DiplomaGED CertificateCertificate of CompletionDid you attend special education classes?YesNoWhy did you drop out of school?Have you attended Adult Education class before?YesNoIf "Yes," where and when?Do you need Childcare Services to attend class?YesNoIf "Yes," list age(s) of child(ren)Do you need transportation to attend class?YesNoIf "Yes," check all that applyDayNightBothIf "Yes," give directions to your house.Are you a registered voter?YesNoIf "Yes," check all that applyCountyTribalDo you have a driver's license?YesNoIf "No," are you interested in getting one?YesNoCheck the one that applies if you had a license and no longer have one:ExpiredRevokedWhat year?Student Signature Clear Signature CDIBSubmit Tribal Profile | Tribal Directory | Employment ©2024 Mississippi Band of Choctaw Indians