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Jamaica Plain Community Centers

ADULT LEARNING PROGRAM

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Mois du patrimoine arabo-américain
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Student Enrollment Form

To enroll, please complete the information below. (Para inscribirse, complete la información a continuación.)

First Name (Nombre)

Middle Name or Initial (segundo nombre)

Last Name (apellido)

Gender *

Male

Female

I choose not to answer

Make a Selection: *

New Student

Returning Student

HiSET - Spanish

HiSET - English

Hernandez K - 8 Student

Curley K - 8 Student

Margarita Muniz Academy

Email

Primary Phone

Date of Birth

Secondary Phone

Place of Birth:

Address:

Street

City

State

Zip Code

Emergency Contact

Emerency Contact Name

Emergency Contact Address

Emergency Contact City & State

Emergency Contact Phone #

Emergency Contact Relationship

Do you have a Learning Disability?

If you have a disability, please describe below:

Social Security #

Select an option *

I have provided a social security number

I do not have a social security number

Public Assistance: Choose all that apply. * Obligatoire

MassHealth

SNAP (Food Stamps)

SSI

WIC

Other

None

How did you hear about ALP? * Obligatoire

Family/friend

Website

Social Media

Poster

INFORMATION

JPCC/ALP

20 South Street

Jamaica Plain, Massachusetts 02130

Information Number: (857) 728-0400

Email: info@jpadulted.org

MBTA Directions

Take the Orange Line to Green Street Station. 20 South Street is a 10 minute walk from the Orange Line at the Green Street stop.

IN PARNERSHIP WITH:

Funding Provided by:

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