Academics
About
Contact
ENROLL
Student Enrollment Form
Student Information
First Name
Last Name
Maiden / Previous Name
Gender
Select...
Male
Female
Date of Birth
Are you 18 years of age or older?
Yes
No
Student Address Information
Street Address
Street Address Line 2
City
State
Indiana
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Phone Number
Email Address
What type of phone is this?
Cell
Home
Work
By providing a phone number, you give The Excel Center. permission to contact you via call and text with reminders and updated information regarding your student status and campus information.
Guardianship Section (if applicable)
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Phone
Relationship
What type of phone is this?
Cell
Home
Work
Student Interest Section
Certified Nursing Assistant
Certified Pharmacy Technician
Welding
Commercial Driver’s License
Certified Veterinary Assistant
Automotive Service Technician
Serve-Safe Certification
College Dual Credits
Other
General Inquiry Questions
Have you ever applied or attended The Excel Center of West Central Indiana?
Yes
No
How did you hear about Excel Center of West Central Indiana? (Check all that apply.)
Internet Search
Social Media
Radio
TV
Newspaper
Family / Friend
Excel Center or Community Event
Registration Questions
Do you or your parents have a first language other than English?
Yes
No
Are you Hispanic or Latino?
Yes
No
What is your ethnicity?
American Indian
Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Other
If applicable, what is the name of the most recent high school you attended?
Are you listed on any Federal or State sexual offender registry?
Yes
No
By submitting, you are verifying that the information submitted in this application is accurate and give The Excel Centerpermission to contact you.
No school owned or operated by The Excel Center of West Central Indiana and Goodwill Workforce Enterprises, discriminates on the basis of race, religion, gender, color, national or ethnic origin, and disablilty in administration of its educational policies, admissions policies,scholarships or other Excel Center-administered programs.
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
