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Adult Education Enrollment Form

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

Student Type: *

Returning Student

New Student

Intake Date

SSN

Last Name *

First Name * (as it appears on your ID)

Middle Name

Suffix

Preferred Name

Home Street Address *

Zip Code *

City *

County

State *

Email Address *

Phone Number * (fill in at least one)

Home Phone

Mobile Phone

Work Phone

Parent/Guardian of: (Check all that apply and list number)

Child(ren) 5 years and younger

If yes, how many and what school?

Child(ren) 6 to 10 years

If yes, how many and what school?

Child(ren) 11 to 18 years

If yes, how many and what school?

Emergency Contact Information

Name of Emergency Contact *

Emergency Telephone *

Employer

Name of Employer

Employer Phone

Employer Address

I understand (must select all 4): *

That student information is confidential and will only be used for program administration, research and evaluation purposes.

I will take all pre/post tests as required.

I will provide a photo I.D. and address verification.

Photo release (select one): *

I agree to have my name or picture/video appear in any Wallingford Adult Education publications.

I do not wish to have my name or picture/video appear in any Wallingford Adult Education publications.

Applicant Signature *

Date *

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.

Check this box to opt in to State Agency Data Matching.

Adult Education Enrollment Form

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

Emergency Contact Information

Employer

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