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Adult Education Application
PLCC Adult Education Application for Admission
City/State of Birth
Date of Birth (mm/dd/yyyy)
Primary Phone Number
Secondary Phone Number
eMail Address (*)
Please list someone that the school may contact in case of an emergency: (other than your home phone)
Ethnic Origin (State Requirement): Please choose all that apply
American Indian or Alaskan Native
Hawaiian or Other Pacific Islander
Citizenship: Please select one
Other immigration status (attach cop of documentation)
Alien lawfully admitted for permanent residency in the Unites States (attach copy of fromt and back of alien registration card)
Check the program name to register
Health & Medical Occupations
Medical Billing & Coding
Business & Computer Training
Automotive Service Technician
Billing and Coding (Prerequisite - Medical Terminology)
Medical Office Procedures (Prerequisite - Medical Terminology)
Anatomy & Physiology
Please check all that apply.
High School Graduate
Some College (no degree)
Other (please list below)
Graduation Date (MM/YYYY)
Pass Date (MM/YYYY)
Please list other here:
Are you currently employed?
Name of the Company
What is your position
Please mark all of the following that apply, failure to disclose any of the following will result in your dismissal
I have been convicted of a misdemeanor (even if you have had it expunged)
I have been convicted of a felony (even if you have had it expunged)
I have been denied a license in Ohio or another state
I have had my license revoked, suspended in Ohio or another state
If you have marked any of the above, please explain
Financial Aid Information
Do you wish to apply for Financial Aid?
If so, you will need to see the Financial Aid Administrator to review your options such as: Pell Grant, loans, WIA, VA, BVR, payment plan, Visa or Mastercard
If male, are you registered with Selective Service
VA Information for anyone who has been in the service
Service Serial #
VA File #
All programs require a $100 deposit to reserve a seat in the class. The deposit includes the WorkKeys assessment and re-test fees, where applicable. If the student does not meet program requirements or the class is not offered, $70 of the deposit will be refunded. PLCC does not accept online payments. Applicants may pay by mail, phone or in person. Cash, checks, money orders, and major credit cards are accepted.
Make checks payable to PLCC and mail to: Portage Lakes Career Center ATTN: Adult Education 4401 Shriver Road Uniontown, OH 44685
Applicant: Read Carefully!
I understand that this application places no obligation upon me or the school with regard to my admission until such time as I am accepted. My application will be reviewed and, if I am accepted, I will be notified by the Office of Adult Education
Yes, I certify that all statements made in this application are true.
Check box for e-signature
The Portage Lakes Joint Vocational School District is an equal opportunity educational institution. Employment and educational programs are offered without regard to race, color, religion, national origin, gender, disability, military status, ancestry or age. The district prohibits harassment of individuals in any form. Concerns of possible discrimination or harassment should be referred to Mr. Michael Kaschak, Compliance Coordinator, at 330-896-8200.
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