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Adult Education Registration

Adult Education Registration Form
Please carefully fill out the form below. Questions? Please call (570) 629-2001 x1125 or email AdultEd@monroecti.org

Registrant Information 

  
First Name: 
Last Name: 
Address: 
City: 
Zip: 
Phone: 
Alternate Phone: 
Email: 
Date of Birth: 
Social Security Number: 
Taxing School District: 
 East Stroudsburg      Stroudsburg      Pocono Mountain      Pleasant Valley      Other     

Course Selection 

Select your Course(s) from the dropdowns below
Courses will only be held if sufficient enrollment is received by the deadline. If a course is cancelled due to low enrollment, registrants will be notified prior to the first night of class and a refund check will be issued. Registration course fees are not transferable and will only be refunded if your course is cancelled. Please note: Under no circumstances will credit card fees be refunded.
Course:  ID:      Start Date:     Course Fee:     Material Fee:
Course:  ID:      Start Date:     Course Fee:     Material Fee:
Course:  ID:      Start Date:     Course Fee:     Material Fee:
Course:  ID:      Start Date:     Course Fee:     Material Fee:
Course:  ID:      Start Date:     Course Fee:     Material Fee:
Course:  ID:      Start Date:     Course Fee:     Material Fee:

Demographic Questions 
 

The following information is requested in order to complete statistical reports which
we must file with the PA Dept. of Education.
Gender: 
 Male      Female     
Ethnicity: 
 Black      White      Hispanic      Asian      Alaskan / American Indian     
  Multiple / No Response     
Special Populations (Check all that apply): 
 Displaced Homemaker Economically Disadvantaged Educationally Disadvantaged
 
 Disabled Limited English Proficiency Single Parent
How did you hear about us?: 
 Returning Student      Brochure      Career Link      Friends/Family      TV      Radio Station

Calculated Costs 

  
Sub Total: 

Liability Waiver

I hereby release Monroe Career & Technical Institute from any and all liability for personal injury or property damage that I may suffer or sustain by reason of use of the school buildings, entrances and exits, the equipment or facilities or as a result of my attendance at Adult Evening School. I understand the course fee will only be refunded if the course is canceled.
I agree

The Monroe Career & Technical Institute is an equal opportunity educational institution