Bellefonte Area School District
High School Diploma Program for Adults
2005-2006 Application

Date____________

1.  Complete the application (please answer all questions).
2.  Mail application to
Jeanne Harvey, Bellefonte Area School District, 318 N. Allegheny Street, Bellefonte, PA 16823
3.  You must be at least 21 years of age.

Applicant: ___________________________________________________________________
                       (Last)                           (First)               (M.I.)               (Social Security #)
Address: _____________________________________________________________________
                        (Street)                         (Apt. #)                        (City)                (State)              (Zip)

Phone:  Home____________   Work____________  Emergency Number____________

Personal Data:    Date of Birth___________________    Age____    __Male    __Female

Names of Children: __________________   Age____   __________________     Age____
                             ___________________   Age____   __________________    Age____

Are you a citizen of the United States of America?  ____ 
In which school district do you reside?  _________________________

Education:  Name of last school attended _________________________   Attended from ______ to _____

Last Grade Completed_______             Reason for leaving school___________________________________

_______________________________________________________________________________
_____

Have you ever taken and passed a GED test?     ____Yes   _____No    If yes, when___________

How did you learn about the High School Diploma Program for Adults?____________________________

____________________________________________________________________________________

Do you have any family members/friends taking this program?  If yes, who? ____________________________

Employment Information:

Name and Address of Employer: _______________________________________________

Job Title_______________________ Type of Employment________________   Date of Employment______

Name of Supervisor_____________________  

Job Responsibilities______________________________________________________________________

Please answer the following questions (in paragraph form) on the back of this sheet:
Why are you interested in earning a high school diploma?
How might you see your life change as a result of earning your diploma?