Logo for: Wallingford Adult Education

Adult Education Enrollment Form

Please fill out the form: (* denotes required fields)
Intake Date
 SSN
Last Name *
 First Name * (as it appears on your ID)
Middle Name
 Suffix
Preferred Name
Program *
 Preferred Class Time *
SASID
 Residence Area
Country Born: *
 Birthdate *
Gender *
 Pronouns
Ethnicity * (check one)
 Race * (must select at least one)
Highest Education Level Completed on Entry:  *
Write in the grade level:*
Write in the grade level:*
Last High School Attended *
 Highest Education Level Location *
Employment Status *
 Miscellaneous Characteristics
(Check all that apply)
How did you hear about Adult Education? *
(Check all that apply)
Home Street Address *
Zip Code *
 City *
County
State *
Email Address *
Phone Number * (fill in at least one)
Parent/Guardian of:(Check all that apply and list number)
If yes, how many?
If yes, how many?
If yes, how many?

Emergency Contact Information

Name of Emergency Contact *
 Emergency Telephone *

Employer

Name of Employer
 Employer Phone
Employer Address
WIOA Core Programs
(Check all that apply)

All Students Must Check One Category Below: *

Do you have low level literacy? *
 Are you experiencing English Language Learner or Cultural Barriers? *

Check all that apply:

1. Cultural Barriers
Do you feel your culture, beliefs, or practices makes finding/keeping a job harder?
2. Disabled
Do you wish to disclose any disability that limits your life activities?
3. Displaced Homemaker
Are you a former homemaker who is having trouble finding a job or a better job?
4. Low Income/Public Assistance
Do you have a low income? Do you receive SNAP, TANF, SSI, or local public assistance? Are you a foster child or homeless?
5. Ex Offender
Do you have a criminal record that makes it hard to find a job? (Do not select this category if you are currently incarcerated)
6. No TANF within 2 years or less
Within two years, will you no longer be eligible to receive Temporary Assistance for Needy Families (TANF) benefits?
7. Foster Care Youth
Are/were you in the foster care system and are under 24 years old?
8. Homeless or Runaway Youth
Are you homeless? Do you lack a regular and adequate residence? Do you live in a motel, hotel, campground, transitional housing or with another person because you lost your house or apartment?
9. Long-Term Unemployed
Have you been unemployed for 27 or more weeks (6-7 months or more?)?
10. Migrant and Seasonal Farmworker
(if yes, select a subcategory)
11. Dislocated Worker
Have you been fired or laid off? Are you unemployed because the place where you worked has closed?
12. Single Parent or Guardian (or single pregnant woman)
Are you a single parent, unmarried or separated and have primary responsibility for one or more children under age 18, or are you a single, pregnant woman?
I understand (must select all 3): *

Photo release (select one): *

Applicant Signature *
 Date *