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E-SESS Student Enrollment Form (Add Participant - Long Form)
Date *

Month Day Year Date Picker Icon
Name *

First Name Middle Name Last Name
Gender *

Female Male
U. S. Citizen: *

Yes No

Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
County *
Only counties in Alabama
E-mail Address
Email Address that you check daily
Race: *

Native American Asian Black White Hispanic Latino Other
Primary Language: *

English French Spanish Other
Educational Attainment: *

Less than High School GED Diploma Associate Degree*
Do you acknowledge a disability? *

Yes No
If yes, what accommodations do you require?

0/500
Totlal Length of Employment *

Less than 6 months 6 months - 2 years 2 - 5 years 5 years +
Are you registered for the draft? *

Yes No Female, not required
Veteran: *

Yes No
MALES BORN AFTER 1960 MUST REGISTER
EMERGENCY CONTACT INFORMATION
Name

First Name Last Name
Relationship
(ex. John Doe or Jane Doe)
Phone #

Area Code Phone Number
Cellular #

Area Code Phone Number
Work#

Area Code Phone Number
DO NOT WRITE BELOW THIS LINE
POST GRADUATE FOLLOW-UP
Advanced Training Credit or Non-Credit:

Yes No
Place of Employment:
Date

Month Day Year Date Picker Icon
Income: *

$0-12,000 $12,000-16,000 $16,000-20,000 $20,000-24,000 $24,001-28,000 $28,001-32,000 $32,001-36,000 $36,001-40,000 $40,001+
Enrolled in Advance Training Credit or Nor-Credit (3 months):

Yes No
Place of Employment:
Date

Month Day Year Date Picker Icon
Retained New
Income: *

$0-12,000 $12,000-16,000 $16,000-20,000 $20,000-24,000 $24,001-28,000 $28,001-32,000 $32,001-36,000 $36,001-40,000 $40,001+
AIDT Pre-Employment Selection/Training
Date

Month Day Year Date Picker Icon
AIDT Pre-Employment Selection?Training (follow-up): *

Interview Accepted No-Show Rejected Withdraw
ENROLLMENT REQUIRED FIELDS
Name, Password, Email address, Mailing address & County, Students Status: In Training
Campus:
Class:
Instructor(s)
Should be Empty:

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