Course Number/Title
Continuing Education
PO Box 1000, 5270 Flat River Road, Park Hills, MO 63601
Continuing Education: 573-518-2342
Days of Week
Last Name
First Name
Social Security Number
Daytime/Message Telephone
Evening Phone:
Student Information
Email Address:
How did you hear about the course?
Class Schedule ___ E-mail ___ Newspaper ___ Facebook___ Friend/Family ___ Employer ___
Radio (circle one): KFMO or KREI or OTHER Other ________________________________________
If another party is paying for this training opportunity, please complete the following for funding purposes:
*ALL information provided is protected by federal law and held in the strictest of confidence.
In accordance with the Family Educational Rights and Privacy Act (FERPA), my signature on this form grants my
employer access to educational records for the course listed on this enrollment form. Educational records include
attendance, completion, grades (if applicable) and copies of certificates which are maintained by the Office of
Workforce Development and/or the Office of Continuing Education.
I understand that I have the right not to consent to the release of my educational records and that I have the right to
inspect any written records released pursuant to this consent. I also understand that failure to release the records for
the course listed above to my employer may result in a transfer of the cost of instruction from the employer to myself.
Student Signature______________________________________________Date_____________________
X__________________________________________________ ___________________________
Signature Date
New Employee (hired in last 6 months)
Black/African American
American Indian/Alaskan
Two or More Races
Native Hawaiian/Pacific Islander
Non Veteran/Military
Active Duty
Military Spouse/Dependant
Date of Birth
Funding Source
Self-Pay ___ WIOA ___ ITA ___ SkillUp ___ Employer ___
Other: _______________________________________________
Pharmacy Technician Program
8/24/20 through 12/17/2020
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