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Adult Education Enrollment Form

Please fill out the form: (* denotes required fields)

Student Type: *

Program *
Preferred Class Time *
Residence Area
Gender *
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)

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


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): *

Data Matching is used to improve Adult Education performance and serve our students. By signing this form, I give permission to the Connecticut State Department of Education to share my data with other agencies.