Student Enrollment Form

Student Information

First Name

Last Name

Maiden / Previous Name

Gender

Date of Birth

Are you 18 years of age or older?

YesNo

Student Address Information

Street AddressStreet Address Line 2

City

State

Zip Code

Phone Number

Email Address

What type of phone is this?

CellHomeWork

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?

CellHomeWork

Student Interest Section

Other

General Inquiry Questions

Have you ever applied or attended The Excel Center of West Central Indiana?

YesNo

How did you hear about Excel Center of West Central Indiana? (Check all that apply.)

Registration Questions

Do you or your parents have a first language other than English?

YesNo

Are you Hispanic or Latino?

YesNo

What is your ethnicity?OtherIf applicable, what is the name of the most recent high school you attended?

Have you previously received any Special Educations services?

YesNo

If yes, please explain.

Are you listed on any Federal or State sexual offender registry?

By submitting, you are verifying that the information submitted in this application is accurate and give The Excel Center permission 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 disability in administration of its educational policies, admissions policies, scholarships or other Excel Center-administered programs.

Thank you! Your submission was received. Please allow up to 3 business days for an Excel Center team member to reach out to you directly.

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Get in Touch

If you have general inquiries about the Excel Center or are interested in joining our team, we would love to chat and answer any questions you may have.