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Jamaica Plain Community Centers

ADULT LEARNING PROGRAM

Use tab to navigate through the menu items.

Use tab to navigate through the menu items.

Student Enrollment Form

To enroll, please complete the information below.

First Name

Last Name

Middle Name or Initial

Gender

Male

Female

I choose not to answer

Make a Selection:

New Student

Returning Student

CNA (Certified Nursing Assistant)

Hernandez K - 8 Student

Curley K - 8 Student

Hurley K - 8 Student

If you are appling for CNA, are you eligible to work in the US?

Yes

No

Email

Primary Phone

Date of Birth

Secondary Phone

Place of Birth:

Address:

Street

City

State

Zip Code

Emergency Contact

Emerency Contact Name

Emergency Contact Address

Emergency Contact City & State

Emergency Contact Phone #

Emergency Contact Relationship

Do you have a Learning Disability?

If you have a disability, please describe below:

Social Security #

Select an option

I have provided a social security number

I do not have a social security number

Public Assistance: Choose all that apply.

MassHealth

SNAP (Food Stamps)

SSI

WIC

Other

None

How did you hear about ALP?

Family/friend

Website

Social Media

Poster

INFORMATION

THIS FORM IS TO REQUEST INFORMATION ONLY

JPCC/ALP

20 South Street

Jamaica Plain, Massachusetts 02130

Information Number: 617-356-7102

Email: info@jpadulted.org

MBTA Directions

Take the Orange Line to Green Street Station. 20 South Street is a 10 minute walk from the Orange Line at the Green Street stop.

Funding Provided by:

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Enter Your Name

Enter Your Email

Phone Number

Select your area of interest

HiSET

ESOL - English for Speakers of Other Languages

College Readiness & Career Pathways

CNA (Certified Nursing Assistant)

Morning

Evening

CNA

This Form is to Request Information Only

Thanks for submitting!

© 2023 JPCCALP.

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