New Student Enrollment Form

Hello there! We are excited that you want to join our free classes. Before we can get started, we need to know a little about you. That is the purpose of this quick survey! You will start by enrolling in classes with our Student Specialist, Amy, and then, at a later date you will complete an initial assessment that allows us to customize your studies so you reach your goals faster.

Complete this form to schedule a date and time to enroll in classes with Amy. Remember, you have the leading role in this process! If your information changes or you need to reschedule an appointment, reach out to us as soon as possible. We are here for you, and all of our services are free of charge!

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Warning

There is currently an issue affecting the enrollment web form that is being checked into. In the meantime, if you do not see the form below. Please call our office M-F 8:00AM-4:30PM to enroll at 276-386-2433. We apologize for this inconvenience.

Note: Our offices are closed April 3rd through April 10th for Spring Break.

"*" indicates required fields

X/Twitter

This field is for validation purposes and should be left unchanged.

Unique ID

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Current Date

MM slash DD slash YYYY

Are you 18 years old or older?

Yes

Persons under 18 are not typically eligible for our services. Please call us at 276-386-2433 for more information and to discuss other options. There is an alternate program, the Individual Student Alternative Education Plan (ISAEP) Program that some students may be eligble for. More information on the ISAEP Program can be found on the Virginia Department of Education website.

Are you a U.S. Citizen or a Documented Immigrant?

Yes

We would be glad to work with you to see how you may become documented. Please call us at 276-386-2433 for more information.

What is your county of residence?*

We have proudly served Southwest Virginia and the surrounding communities for over 30 years!

Your Address*

Address Address Line 2 City State ZIP Code

It looks like you are from an area that is outside of our region. We recommend looking for an adult education provider close to you. If you are in Virginia, we suggest this page from the Virginia Department of Education website.

If you are from another state, we recommend entering your location into this map from the GED Testing Service website.

If you are having trouble finding a local program or would like to talk to us relating to your specific situation, please call us at (276)-386-2433, Monday-Friday 8AM to 4:30PM.

Contact Information

Your Name*

First Last

Your Email

Enter Email Confirm Email

Your Phone Number*

What phone number should Amy call?

Is the above phone number a cell phone number?*

Yes

May we text you via this number if needed?*

Yes

Enrollment Appointment Information

We start our new program year on July 1st. Due to that, depending on the current date, there may not be any selectable registration dates until then. If so, please try back closer to July 1st.

Enrollment Appointment Date*

What is a good day that Amy can call you to get you enrolled? (Monday-Friday)

MM slash DD slash YYYY

Enrollment Appointment Time*

What is a good time that Amy can call you to get you enrolled? (Please allow up to 15 minutes after the time you selected in the event that Amy is working with another student and cannot call at the exact time you selected.)

Please make sure the selected date is not a past date. Thanks!

Your Rights & Student Information

Please read the below statements and select if you agree.

Release of Student Information Consent*

I authorize the state, district, or territory to whom this release is submitted (collectively, the “State”) and my local Adult or Technical Career program or college to use, report, and release the Personally Identifiable Information (PII) contained in my Adult Education program records, instructional plan, assessment outcomes, credential progress and attainment, and accommodation documentation (if any was provided) and to access, use, and report my Employment Data (unemployment and wage records), for purposes of education and/or employment research, planning, and reporting as required by state policy and federal regulations. This will include follow-up employment data and other educational records and information that will only be reported in aggregated form. I understand that government files will be accessed to obtain this information and will only be used for the purposes mentioned herein without specific authorization for any other use.

I acknowledge that the State fully supports the mandates of the federal Family Educational Rights and Privacy Act (FERPA) and 20 CFR, Chapter V, 603.5(d)(2)(i).

I understand these statements fully and authorize the use of my “program” PII and employment data for official purposes only, as approved by my signature below.

Regional Adult & Career Education (MyRACE1) is committed to a policy of non-discrimination and follows federal laws to protect your student education records also known as Family Educational Rights and Privacy Act of 1974 (FERPA).

You can read more about FERPA here: Department of Education - Family Educational Rights and Privacy Act

You agree your electronic signature is the legal equivalent of your manual signature on this Release of Student Information Consent statement.

Yes, I approve

By selecting the "Yes, I approve" option, I understand these statements fully and authorize the use of my “program” PII and employment data for official purposes only, as approved by my signature below. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Student Information Consent statement.

Consent to Release Student Information for Determining Additional Workforce Assistance Eligibility

By selecting the "Yes, I approve" option, I authorize my adult education provider to release my directory information to workforce agencies at my local Virginia Career Works to determine if I qualify for additional workforce assistance, including occupation-specific training. The signed consent is valid while I am enrolled in this program.

You agree your electronic signature is the legal equivalent of your manual signature on this Release of Student Information Consent statement.

Yes, I approve