38.14 Registration Form - Jail Officer Academy

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Jail Officer Academy Registration Form

Step 1 - Demographic & Address Information

Today's Date:

Last Name

First Name:

Middle Initial

Job Title:

Former Name/s (if applicable):

Student ID # (if known):

Mailing Address:

City:

State:

Zip Code:

County:

Legal Resident of:

Primary Phone:

Phone Type:

Secondary Phone:

Phone Type:

Is MPTC allowed to text updates?

Gender:

Date of Birth:

Social Security Number:

U.S. Citizen?

Are you Hispanic or Latino? (Cuban, Mexican or Puerto Rican, South or Central American regardless of race)

Choose one or more from the following that bests describes your race:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian/Pacific Islander

White

Personal email Address:

Are you a high school graduate?

If you did not graduate, did you complete a GED/HSED?:

Date of HSED/GED Completion:

Step 2 - State Data Survey:
Please answer the following questions. This information is requested for state and federal reporting purposes only. When reported, this information is not personally identifiable. Moraine Park Technical College maintains this information in compliance with FERPA and federal privacy requirements. Accurate data enables Moraine Park to obtain state and federal funding that supports education and service to our students. Your response is appreciated.

1. Highest Grade Completed at enrollment:

2. Highest Credential Received at enrollment:

3. Highest degree earned by either parent:

4. Veteran Status:

5. Work Status at Enrollment:

6. Single Parent:

(Are you single, separated, divorced, or widowed and raising children under age 18?)

7. Disability:

8. Foster Care Youth:

(Are you between the ages of 16-24 and are or were part of the foster care system?)

9. Do you meet the criteria for being homeless?:

(In the past year have you been homeless? This could include living in your car, sleeping on a friend's couch, staying in a shelter or living in temporary housing - like a motel).

10. Parent in Armed Forces:

(Are you between the ages of 16-24 with a parent on active duty in the armed forces?)

8. Economically Disadvantaged:

(Includes any individual or member of a family who is unable to pay for one or more basic living needs, who receives need-based financial assistance, or whose income is at or below the poverty level as defined by the U.S. Department of Health and Human Services.)

Step 3 - Registration for Classes

CRN

Class Title

Subject/Course

Start/End Date

44692

Jail Academy

504-446

9/14/2026 - 10/16/2026

Step 4 - Employer Information

Employer Name:

Employer Phone Number:

Employer Address:

City:

State:

Zip Code:

Step 5 - Agreement / Submit Registration

By submitting this form:

I certify that the above information is correct. I authorize Moraine Park Technical College to release confirmation of my registration and any academic records related to this training to my employer or personnel/training officer sponsoring the training.

Full Name:

Moraine Park Technical College collects your Social Security Number for record keeping and statistical purposes related to auditing, enforcing, and evaluating federally supported education programs (Federal Law 20 U.S.C.s. 1232g (1998)) only. You are required to provide your Social Security Number for IRS 1098T tax reporting.

Moraine Park Technical College is an equal opportunity and affirmative action College. Women, minorities, those with different abilities and veterans are encouraged to apply. For more information, visit morainepark.edu/nondiscrimination.

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