Kentucky Department of Education
Office of Career and Technical Education
Carroll Co. ATC Enrollment Form
Program: Career Pathway:
Objective: Preparatory Exploratory
*3 or more classes or 2nd year in program. *1 or 2 classes or 1st year in program
Last Name: First Name: Middle Name:
Address: City: Zip:
Social: - - Date of Birth: / / Home Phone:
Email: Home High School: State ID:
Race: Sex:(circle one) Male Female Current Grade Level:(circle one) 9 10 11 12
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DISABILITY DISADVANTAGE GENERAL
Autism Academic IEP on file
Deaf/Blind Economic IGP on file
Emotional Behavioral Disorder Both Tech Prep
Functional Mental Disability PreReqs Met
Hearing Impairment Work Study
Mild Mental Disability Nontraditional Prog Financial Aid
Multiple Disability Single Parent Co-op
Orthopedic/physical Impairment Single/Pregnant Women
Other Health Impairment Displaced Homemaker
Speech/Language Impairment Limited English Prof.
Attendance Period: (circle one) 1 2 3 4 5 6 7 Hours: (circle one) 1 1.5 2 2.5 3 3.5 4 4.5
With whom do you live with (circle one) Mother Father Guardian Stepmother Stepfather Other
Name of Mother or Guardian: Home Phone:
Employer: Work Phone:
Name of Father or Guardian: Home Phone:
Employer: Work Phone:
IN CASE OF AN EMERGENCY PLEASE NOTIFY:
Name: Relation:
Phone Number(s) Home: Work:
OR:
Name: Relation:
Phone Number(s) Home: Work:
ACCEPTANCE OF RULES AND REGULATIONS
I understand and accept the rules set forth in the Student Handbook of
the Carroll County Area Technology Center as long as I am enrolled at
the center.
Student Signature: Date: