Fall 2024-2025 Application

Welcome to the 2024 - 2025 school year!

Please complete the form below and submit to begin your classes with Pasco County Schools Adult Education.

All PHSC - DADE CITY ESOL Sessions are full. MTC ESOL Evening Sessions are Full. Anyone who submits an application will be added to the waiting list.

Due to updates to testing requirements, all GED and ESOL (new and returning) students must complete the CASAS pre-enrollment test before their first day of school. Completion of the enrollment testing is mandatory for continued class enrollment. Links to schedule your testing will be provided after submission of this form.

You will receive an email or phone call to confirm your enrollment and testing status prior to the first day of school.

Please Note: Tuition fees are due when you apply and are non-refundable.

What is your preferred location? *

What is your preferred program? *

What is your preferred diploma option? *

ACCEL 18 Credit option requires the same courses as the Standard 24 Credit option except a student only needs three electives; physical education and an online course are not required. This option cannot be changed after enrollment.

What is your preferred schedule? *

What is your Pasco County School's Student ID number - 6 digits (if applicable)

First Name*

Middle Name

Last Name*

Former or Maiden Name

If not applicable, please write N/A in the text field

Student's Date of Birth*

Date

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security Number*

Gender*

MaleFemale

Birthplace: City*

Birthplace: State or Country*

Are you of Hispanic or Latino Ethnicity?*

YesNo

What is your race?*

Citizenship:*

Are you limited English proficient?*

YesNo

What is the primary language spoken at home?*

Are you a United States Veteran?*

YesNo

Employment status:*

EmployedUnemployed, Seeking EmploymentUnemployed, Not Seeking EmploymentEmployed, but received notice of termination of military separation

Have you been referred by an agency?*

What is the highest level of education you have completed?*

Highest school grade completed:*

Where was this level of education achieved?*

U.S based schoolNot U.S. based school

If you have a disability that you plan on disclosing, which of the following apply to you?*

Parental Status:*

Single ParentSingle Pregnant WomanBoth - Single Parent and PregnantNot Applicable

Do any of the following apply to you as a Displaced Homemaker?*

Participant is providing service to family members in the home and is the dependent spouse of a member of the Armed Forces on active dutyParent whose youngest child will become ineligible (at age 16) to receive assistance under the program for Aid to Families with Dependent Children under Part A of the Title IV of the Social Security ActBeen dependent on public assistance or on the income of a relative but is no longer supported by such incomeWorked as an adult primarily without remuneration to care for home and familyNot Applicable

Have you previously been or are you currently now subject to any stage of the criminal justice process?*

Ex-OffenderNot Ex-Offender

Do you perceive any barriers with employment?*

No, I do not perceive hindrance to employmentYes, I do perceives hindrance to employment

Homelessness: Do any of the following conditions apply to you?*

Lack fixed, regular, and adequate nighttime residencePrimary nighttime residence not designed for human sleeping accommodationMigratory ChildUnder 18 and absent from legal residenceDo not meet any of these conditions

Migrant and Seasonal Farmworkers:*

MigrantSeasonal FarmworkerDo not meet either of these conditions

Military Status: Please select your military status:*

Income Status: Select the choice that applies to your income status at the entry to your program.*

Participant will exhaust Temporary Assistance for Needy Families (TANF) within two years of program entry.Participant has been unemployed for 27 or more weeks at time of program entry.Participant identifies as low income at program entry.None of the above applied to me at the entry of my program.

Please read the PASCO COUNTY SCHOOLS STUDENT CODE OF CONDUCT

I understand that I must read and agree to the Pasco County Schools Student Code of Conduct (above) to finalize this application.*

I have read and agree to the Pasco County Schools Student Code of Conduct

I acknowledge that I will be enrolled in an adult education program that serves individuals of varying ages. As a participant in this program, I am regarded as an adult and am therefore expected to conduct myself accordingly. The program does not employ a grading system; however, periodic assessments will be conducted to gauge academic progress. Students must maintain regular attendance, adhere to proper campus etiquette, and demonstrate a professional demeanor throughout their time on any Pasco County Schools’ Campus.

Recognizing the significance of attendance and proper behavior in achieving success on the GED exams, I understand the importance of regularity in my attendance and proper campus behavior. Should I accumulate excessive tardies or absences, it may be necessary for me to engage in a meeting with the teacher, academic advisor, or administration to discuss an improvement plan. Should I display inappropriate behaviors; it will be necessary to discuss an improvement plan with the teacher, academic advisor, or administration. Failure to demonstrate improvement in attendance or behavior despite the implementation of a plan may result in my withdrawal from the program. Therefore, it is expected that students arrive on time for each session, remain in class until released by their teacher, and demonstrate a professional disposition.

I understand that access to my educational records, including items such as admission, enrollment, tuition, academic standing, and disciplinary records, will only be granted to those individuals listed on the FERPA Release section of this application.

Any student that violates the Pasco County Schools Zero Tolerance Policy in regard to illegal drugs, alcohol, or tobacco, or engages in a physical disturbance will be immediately removed from the program.

I acknowledge the Enrollment Agreement and understand that smoking, vaping, and/or use of tobacco of any kind while on campus violates the Pasco County Schools Student Code of Conduct and will subject me to removal from my program.

Emergency Contact Notification

Pasco County Schools Adult Education Emergency Information
(Please fill in the fields below for information to be used in case of emergency)

Name of Emergency Contact #1*

First NameLast Name

Relationship of Emergency Contact #1*

Phone Type of Emergency Contact #1*

Phone Number of Emergency Contact #1*

Please enter a valid phone number.

Name of Emergency Contact #2 (optional)

First NameLast Name

Relationship of Emergency Contact #2

Phone Number of Emergency Contact #2

Please enter a valid phone number.

Phone Type of Emergency Contact #2

List any medications, health problems or allergies that the school should be aware of:

Family Educational Rights and Privacy Act (FERPA)

In accordance with the Family Educational Rights and Privacy Act (FERPA), an adult student’s educational records are confidential and can only be viewed and/or discussed with the student. Students may authorize Pasco County Schools Adult Education staff to discuss their educational records with another individual or agency by including them on a FERPA Release Form. They can obtain a FERPA Release Form in the student services office at any time after enrollment.

Adult students or the parent/guardian of minor students may inspect and review the records of that student in the presence of authorized personnel. Adult students or parent/guardians of minor students may request information in that student’s file be disclosed or released. The request must be in writing and shall include the following (State Board of Education Rule 6A-1.0955):

1. Must be signed and dated by the person making the request.
2. The records to be disclosed must be specifically identified.
3. Purpose of disclosure must be listed.
4. The party to whom the release is being made must be identified.
5. Each request for information to be released must be made separately.

In addition, the District may choose to publish and/or display this information in District sponsored publications, at various school or public functions, on the District’s local cable channel, website(s) and various social media channels, or in the school yearbook. While the intent of this practice is to be informative and celebratory, the District recognizes that concerns may arise regarding a student’s right to privacy.

Pursuant to the Federal Family Educational Rights and Privacy Act (FERPA), school districts are permitted to release "school directory information" unless applicants exercise their right of refusal. Under the FERPA law, this information could include: student name, residential address, e-mail address, phone numbers, photographs/images, school locations, field of study, degrees, honors and awards received and participation in athletics and other activities.

It is the intent and practice of the School District to publish, post, or release ONLY an applicant’s name,photograph, audio and/or video recording, displays of student work or other school-related information and ONLY as related to student achievement (e.g. academic/athletic recognition or award) or student accomplishment (e.g. a specially selected piece of work).

AUTHORIZATION FOR ACCESS TO MY EDUCATION RECORD (FERPA)

In accordance with the Family Educational Rights and Privacy Act (FERPA), I authorize Pasco County Schools Adult Education staff to release my education records to the following persons, agencies or organizations for the purpose of keeping such persons, agencies or organizations informed of my progress within the Pasco County Schools Adult Education Programs

If you do not want anyone to access your education records, please indicate that below; otherwise, complete the contact information (FERPA):

I do not want anyone to access my education records (FERPA)

Contact Information for FERPA

First NameLast Name

Relationship for FERPA Contact

Phone Number for FERPA Contact

Please enter a valid phone number.

I understand that by checking the box below. I am waiving my rights of nondisclosure of these records under federal law only to the persons or entities specifically listed. This release does not permit the disclosure of these records to any other persons or entities without my written consent or as permitted by law. This consent will remain in effect until revoked by me in writing.*

I have read and agree to the statement above.

RELEASE OF INFORMATION CONSENT FORM

• I authorize the review of my test scores; including but not limited to GED(R) Ready Tests, Official GED(R) Tests, and CASAS test scores by parties such as adult education administrators, teachers, MIS staff, or other employees of the District School Board of Pasco County. This information is used for teaching and reporting purposes.

Release of Information Consent form agreement*

I confirm that I have read and authorize the release of information consent form

NOTIFICATION OF INSPECTION FOR ASBESTOS CONTAINING MATERIALS IN PUBLIC SCHOOLS

NOTICE TO BUILDING OCCUPANTS AND PARENTS

The Environmental Protection Agency (EPA) has issued a final rule, 40 CFR Part 763, Asbestos Containing Material in schools, commonly referred to as AHERA. This rule requires all Local Education Agencies (LEA’s) to identify asbestos containing materials (ACM) in their school buildings and to take appropriate actions to control the release of asbestos fibers.

All inspections for Pasco Hernando State College - Dade City Campus have been completed and a Management Plan describing the results of the inspection and the action plan to control any asbestos found during the inspection, where applicable, has been submitted to the governor for approval.

NOTIFICATION OF INSPECTION FOR ASBESTOS CONTAINING MATERIALS IN PUBLIC SCHOOLS*

I Have Read The Above Statement

PASCO COUNTY SCHOOLS MEDIA RELEASE FORM

Pasco County Schools (the District) strives to celebrate the accomplishments of its students by sharing information with the community. To do this, the District may submit press releases to local media (newspapers, radio, television, online news blogs) that include student names, student work,student photographs, and video and/or voice recordings.

In addition, the District may choose to publish and/or display this information in District sponsored publications, at various school or public functions, on the District’s local cable channel, website(s) and various social media channels, or in the school yearbook. While the intent of this practice is to be informative and celebratory, the District recognizes that concerns may arise regarding a student’s right to privacy.

Pursuant to the Federal Family Educational Rights and Privacy Act (FERPA), school districts are not permitted to release "school directory information" unless applicants exercise their right of refusal. Under the FERPA law, this information could include: student name, residential address, e-mail address, phone numbers, photographs/images, school locations, field of study, degrees, honors and awards received and participation in athletics and other activities.

It is the intent and practice of the School District to publish, post, or release ONLY an applicant’s name,photograph, audio and/or video recording, displays of student work or other school-related information and ONLY as related to student achievement (e.g. academic/athletic recognition or award) or student accomplishment (e.g. a specially selected piece of work).

I understand that if I do not wish to grant permission to Pasco County Schools to release my information as defined above I must complete a Media Release Form that must be completed by me, in person, at the administration office on campus.*

I have read and agree to these terms and conditions

Responsible Electronic Use Guidelines for Students

I have access to the Internet, school networks and electronic devices so I can…
expand my learning;
communicate with others about what I am learning;
research topics for class projects or for my personal learning;
create products highlighting my learning;
learn how to be a responsible and productive digital citizen.

Here are some things I need to know:
Electronic devices include but are not limited to computers, netbooks, iPads, iPods, tablets, cell phones, cameras, and other electronic devices that allow me to create and communicate.
I am responsible for all my online activities that take place through the network connection with my school’s devices or through access with my own personal electronic devices.

I am responsible for obeying all laws, including copyright. This also means I may not use the District logo or other District-owned content on my personal posts.

I do not have the right of privacy when accessing the Internet or network while at school.
Communicating electronically includes using my camera and cell phone to communicate visually.
When communicating electronically, I should ask myself: Is it safe? Is it kind? Is it respectful? Is it appropriate?

I do not have an absolute right to take, publish/post photographs or videos of others at school, as it may impact their individual rights of privacy.

Bullying or harassing someone either in person or electronically is wrong, violates the Code of Student Conduct, and is against the law.
Information I find on the Internet is not necessarily true or accurate.
There are filters to prevent access to inappropriate information, but no filter is perfect. I must protect myself by knowing how to close a window or click on the back button.

I can learn more about being a responsible digital citizen at http://www.safeflorida.net/safesurf.
Here’s what I agree to do as a responsible and productive digital citizen:

I will follow all school rules and laws when using electronic devices at school.

I will not damage equipment, upload harmful files, damage files, delete files, or access someone else’s files because it impacts others.

I will keep my password to myself and will not share it with others.

I will not search for or try to access obscene, harmful, or inappropriate material.

If I accidentally access inappropriate materials, I will close the window and tell a responsible adult.

I will not post or send hurtful, offensive or inappropriate material.

I will behave honestly, fairly, and with integrity when posting online, including my social networks.

I will follow rules of network etiquette, and I will be polite when communicating with others electronically. I will not use bad language or access messages from others who use bad language.

I will not post or share pictures of others without their knowledge and approval.

I will stay safe and will never meet or give out personal information such as my name, phone number, or address to someone I meet on the Internet without the express permission of my parents and/or teachers.

I will discuss my online activities with my parents so they understand how I am learning to be a good digital citizen.

My teachers and administrators have the right to access whatever I do online while in school if they are concerned about my safety or the safety of others.

I will not use others’ work without permission or without citing their work according to copyright laws.

If I’m not sure how to do something or whether something is okay to access or do, I will ask a responsible adult.

What happens if I violate this agreement and am not a responsible digital citizen?
Violations of this agreement will result in disciplinary action according to the Code of Student Conduct.

I have read The Terms and Conditions of the Responsible Electronic Use Guidelines for Students*

I Confirm That I Have Read And Agree To the Responsible Electronic Use Guidelines for Students

Disability Disclosure

Pasco County Schools (the District) hereby stipulates and affirms its policy of offering equal educational opportunities for all persons regardless of race, color, ethnicity, religion, national origin, age, gender, marital status, disability, genetic information or legally-protected characteristic. As such, it is the policy of the District to provide reasonable substitutions for any person enrolled in a postsecondary vocational programs who is hearing impaired, visually impaired, dyslexic or who has a specific learning disability where failure to meet the requirements is related to the disability. In order to receive disability accommodations or substitution, qualifying students must provide documentation that clearly shows evidence of a disability to the Special Populations Coordinator for individual consideration. The Special Populations Coordinator may be contacted at (727) 774-1731.

Confirm That You Have Read The Disability Disclosure*

I Have Read The Disability Disclosure

Medical Emergency Care Treatment Authorization:
In case of accident or serious illness, I authorize the school to make whatever arrangements are necessary to provide care and treatment. I agree to pay all expenses incurred by the handling of this emergency care.

Medical Emergency Care Treatment Authorization Agreement*

I agree with the statement above.

Affidavit
I certify that the information on this application is correct to the best of my knowledge. By clicking the checkbox below I hereby agree to all the information provided and furthermore give my permission for the use of this data included herein in managing the program for which I am registered.

Affidavit Agreement*

I agree with the statement above.

Terms and Conditions

By submitting this Application, I hearby agree to pay the tuition fee of $31.20 for the school Term of which I am applying for. I further understand that at the start of each new Term the tuition fee required is to be re-submitted to secure my continued enrollment.

TERMS & CONDITIONS*

I Have Read And Understand The Above Terms And Conditions

I understand that application fees are non-refundable.*

I understand

CHOOSE ONLY ONE OPTION BELOW:*

ESOL FALL Tuition FeeTuition fees are non-refundable

$31.20

ABE/GED FALL Tuition FeeTuition fees are non-refundable

$31.20

Adult High School or Graduate 24/7 FALL Tuition FeeTuition fees are non-refundable

$46.35

Total

$0.00

Credit Card Information

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Fall Adult Education Application

Enrollment Agreement: