Omega School Student Enrollment Form

Last Name: (required)
First Name: (required)
Middle Initial:
What name do you want to go by at Omega School?
Social Security Number:
Date(required):
City:
State:
Zip:
Home Phone:
Cell Phone:

Education Completed:	(Write in the highest grade completed in the United States)
The highest grade I completed was:
Name of school:
Name of country(if educated outside of the United States):

Hobbies and Interests:

Educational Goal:	(choose all that apply)
	Obtain GED Diploma Obtain the HSED Diploma Enter College or Technical School Read to my children Study for an Appresticeship or trade

Employment Status:	(choose one)
	Employed part-time Employed full-time Unemployed (looking for work) Not in labor force (not looking for work) Collecting disablility
Employer (if working):

Family Status:	(choose all that apply)
	Parents of children (ages 1-17) Single Living with Parents Living with Friends Homeless

Key Contact Person:	(Name and address of someone who wants you to complete GED or HSED?)
Name:
Home Phone:
Address:
Email:

Omega School, Inc. 835 W. Badger Rd. Madison, WI 53713 Phone (608) 256-4650F Fax (608)256-4651