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Form: 2012-2013 Online Enrollment Form
User: User, Guest
Status: Draft
2012-2013 JTED Enrollment Form

Welcome to the Pima County JTED Central Campus Enrollment Form. Upon completion and submission of your information, you will receive a confirmation email. You must fill out all required fields in order to submit the form.

Note: All submissions and drafts will be deleted at the end of the week, after which you will not be able to view or make changes to your form.

If you have any questions, please contact us at 520-352-5833.
(required) 1. Please enter TODAY'S DATE:
(mm/dd/yyyy format)
(required) 2. Student's Email address:
(required) 3. Student's FIRST name:
4. Student's MIDDLE name:
(required) 5. Student's LAST name:
Program of Interest
(required) 6. Choose the program and location you are most interested in.
If you are interested in or want to enroll in more than one program, please call Enrollment Services at 512-5261.

Selecting a program does not mean you are automatically in the class. You must attend a registration/orientation meeting and have submitted all required paperwork.
Placement is on a first-come, first-served basis. Some programs have prerequisites, other requirements and/or an enrollment deadline. For more details, refer to the Program Guide at www.pimajted.org

Please choose one program and location preference.
7. Have you taken one of these Pima County JTED Central Campus classes before?
If so, which class?
Student information
8. Student's cell phone #: (xxx-xxx-xxxx)
(required) 9. Gender:
(required) 10. Date of Birth (mm/dd/yyyy):
11. Home Address NUMBER (house number):
(required) 12. Home Address STREET (or P.O. Box):
13. Home Address Apartment / Unit #:
(required) 14. Home address CITY:
(required) 15. Home address STATE:

(required) 16. Home Address ZIP CODE:
17. Mailing Address (if different from above):
(Number/Street/Apt., City, State, Zip)
(required) 18. Ethnicity: are you Hispanic or Latino?
(required) 19. Please indicate your race: (check all that apply)
You must choose at least one. If you do not fit any of the first four categories listed, choose White.
(required) 20. What is your primary language?
21. Specify your primary language, if you chose "other":
(required) 22. What is the language most spoken at home?
23. Specify the language most spoken at home, if you chose "other":
(required) 24. What grade will you be in next year (2012-2013)?
(required) 25. What high school do you attend?
26. OTHER high school (if your school was not listed above):
27. Do you have:

- an IEP (Individualized Education Program -- receive Special Education services)
     or
- 504 Accommodations (medical or other accommodations that are not Special Education)?

Parent/Legal Guardian #1 information
(Primary parent/guardian)
(required) 28. Parent/Legal Guardian #1 FIRST name:
(required) 29. Parent/Legal Guardian #1 LAST name:
30. Parent/Legal Guardian #1 Email address:
(required) 31. Parent/Legal Guardian #1 relationship to student:
32. Parent/Legal Guardian #1 Address if different from student's address above:
(number/street/apt.)
33. Parent/Legal Guardian #1 Address  if different from student's address above:
(city, state, zip)
(required) 34. Parent/Legal guardian #1 primary/home phone #: (xxx-xxx-xxxx)
35. Parent/Legal guardian #1 secondary/cell phone #: (xxx-xxx-xxxx)
36. Parent/Legal Guardian #1 - language spoken:
(required) 37. Does Parent/Legal Guardian #1 have legal custody of the student?
(required) 38. Does the student live with parent/legal guardian #1?
(required) 39. Is it OK for parent/legal guardian #1 to pick up the student from class/school?
(required) 40. Does Parent/Legal Guardian #1 receive mailings for the student?
Parent/Legal Guardian #2 information
41. Parent/Legal Guardian #2 FIRST name:
42. Parent/Legal Guardian #2 LAST name:
43. Parent/Legal Guardian #2 Email address:
44. Parent/Legal Guardian #2 relationship to student:
45. Parent/Legal Guardian #2 Address if different from student's address:
(number/street/apt.)
46. Parent/Legal Guardian #2 Address if different from student's address:
(city, state, zip)
47. Parent/Legal guardian #2 primary/home phone #: (xxx-xxx-xxxx)
48. Parent/Legal guardian #2 secondary/cell phone #: (xxx-xxx-xxxx)
49. Parent/Legal Guardian #2 - language spoken:
50. Does Parent/Legal Guardian #2 have legal custody of the student?
51. Does the student live with parent/legal guardian #2?
52. Is it OK for parent/legal guardian #2 to pick up the student from class/school?
53. Does parent/legal guardian #2 receive separate mailings from parent/legal guardian #1?
NOTE: If there is a custody dispute, you must provide legal documentation to place on file.
Local Emergency Contacts (Other than parent/legal guardian listed above)
List in order of contact priority
Emergency contact #1 information:
54. Emergency contact #1: First name
55. Emergency contact #1: Last name
56. Emergency contact #1 relationship to student:
57. Emergency contact #1 phone number: (xxx-xxx-xxxx)
58. Emergency contact #1 - language spoken:
59. Is it OK for emergency contact #1 to pick up the student from class/school?
Emergency contact #2 information:
60. Emergency contact #2: First name
61. Emergency contact #2: Last name
62. Emergency contact #2 relationship to student:
63. Emergency contact #2 phone number: (xxx-xxx-xxxx)
64. Emergency contact #2 - language spoken:
65. Is it OK for emergency contact #2 to pick up the student from class/school?
Emergency contact #3 information:
66. Emergency contact #3: First name
67. Emergency contact #3: Last name
68. Emergency contact #3 relationship to student:
69. Emergency contact #3 phone number: (xxx-xxx-xxxx)
70. Emergency contact #3 - language spoken:
71. Is it OK for emergency contact #3 to pick up the student from class/school?
Emergency Medical Information
72. Physician's Name:
73. Physician's phone #:
74. Does the student have medical insurance?
75. Name of Medical Insurance:
76. Name of Insured:
77. Medical Insurance policy #:
(required) 78. Does the student have any medical conditions?
79. Please list and explain any medical conditions:
(required) 80. Does the student take any medications?
81. Please list any medications the student takes:
JTED Contracts and Agreements
Attached is a copy of Pima County JTED's Contracts and Agreements. Please indicate that you and your parent/legal guardian have read and accept the terms and conditions. (This document is also available online at www.pimajted.org)
JTED contracts condensed 11.1.11.pdf     
(required) 82. ELIMINATING GUNS AND WEAPONS FROM SCHOOL

I have read and agree with the District's contract terms regarding guns and weapons.
(required) 83. INTERNET USE

I have read and agree with the District's Electronic Information Services use agreement terms.
(required) 84. PHOTO RELEASE AUTHORIZATION

I have read and agree with the District's Photo/Video release terms.
(required) 85. FIELD TRIPS

I have read and agree with the District's release of liability for Travel and Experiences outside the classroom.
(required) 86. MATERIALS / SERVICES AGREEMENT

I have read and agree with the District's materials / services terms.
Required Documents

In order to be enrolled in a JTED Central Campus class, you will need to submit:
   - a copy of your birth certificate
   - a copy of your current immunization records


87. How did you hear about JTED? (check all that apply)

88. Attach a copy of your birth certificate here, or you may fax to 520-352-5842.

Browse for your file, then you must click the "Attach" button. You will need to scroll back down to this point of the survey to continue.

  
89. Attach a copy of your current immunization records here, or you may fax to 520-352-5842.

Browse for your file, then you must click the "Attach" button. You will need to scroll back down to this point of the survey to continue.

  
90. For COSMETOLOGY, CERTIFIED NURSING ASSISTANT, CAREGIVER, and MEDICAL ASSISTANT only--prospective students for these programs must submit a copy of their most recent high school transcripts (through Fall 2011).

Attach a copy of your transcripts here, or you may fax to 520-352-5842.

Browse for your file, then you must click the "Attach" button. You will need to scroll back down to this point of the survey to continue.

  
Thank you for enrolling online. You will receive an email confirmation shortly.

- Remember to check your email for important JTED enrollment updates.
- It is the student/parents' responsibility to notify JTED of any information changes.
- If you have any questions about enrollment, contact Lori D'Anna at 520-512-5261.