WFD Registration Form Name * Required First Middle Last Last 4 digits of SSN * RequiredDate of Birth - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Email Address * Required Sex * Required Male Female Other Race * Required American Indian Alaskan Native Asian Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White Other Address * Required Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone Number * Required Emergency Contact Name * Required First Last Emergency Contact Phone * RequiredADA: Do you require any special accommodations under the American Disabilities Act? * Required Yes No If yes, explain * RequiredEducation * Required College Graduate High School Graduate GED High School Student Military * Required Veteran Transitioning Service Member Active Duty Military Military Spouse N/A Employment: Are you currently employed? * Required Yes No If yes, where? * Required Course NameClinical Medical AssistantPhlebotomy TechnicianWelding TechnologyPrivate PianoPrivate VoicePrivate ViolinAlexander TechniqueACT PrepPrivate GuitarGrowing Heirloom TomatoesSummer Camp: Adulting 101Summer Camp: Science AdventuresSummer Camp: Fun with GuitarSummer Camp: Babysitters ClubDate Beginning - must be mm/dd/yyyy format * Required MM slash DD slash YYYY REFUND POLICY AND PANDEMIC STATEMENT: Withdrawal prior to first class meeting, full refund. Withdrawal after class mtg. but prior to second class mtg., 75% refund. After second class meeting, no refund will be given. In the event Snead State should experience the need for all in-person classes to transition to remote instruction due to the pandemic or other event warranting the need for such plans, such communication will be provided to the students. This communication will provide details to the program’s remote instructional plan to complete the necessary theory, lab and/or clinical to meet the course objectives necessary for successful completion in a remote environment. For further information contact Teresa Walker or Cherri Barnard. By signing this form I acknowledge I have read and understood the refund policy and WFD Terms and Conditions found at www.snead.edu/workforce.Student Signature * Required First Last Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY CAPTCHAT-Shirt Size (Summer Camp Only) * RequiredChild SmallChild MediumChild LargeChild XLAdult SmallAdult MediumAdult LargeAdult XLAdult 2XL
