Student Information

"*" indicates required fields

First Name

Middle Name

Last Name

Please type your name as it appears on legal documents.

Mobile Phone

We communicate important messages to students via text message. If you do not currently have a mobile phone, please list a mobile phone number of a trusted family member or friend so that you can receive messages.

Gender

Male

Female

Date of Birth.

Age

Please select the goal you would like to accomplish with us.

If you have more than one goal, select the first goal you need to accomplish.

I need to learn English.

I want to earn a High School Equivalency Diploma (GED) or High School Diploma Option (HSDO)

I want to earn a career certification.

Are you currently a student at any high school in the state?

Yes

Street Address

City

State

Zip Code

In which county do you live?

In which country were you born?

Please upload a favorite photo of yourself so that we can use it for your student profile.

Please include only your head and shoulders in the image.

Home Phone

This is not required.

Work Phone

This is not required.

Emergency Phone

What is the phone number of a trusted person we can contact if we cannot reach you?

Social Security Number

We do not require you to provide your social security number, but providing it helps us to track your accomplishments as well as any resources we might be able to provide for you. As always, we keep all data secure.

LANGUAGE

What is the primary language you speak?

English

Non-English

Ethnicity

Please select the ethnicity that best describes you. You may select more than one.

Black or African American (Person having origins in any of the black racial groups of Africa)

American Indian or Alaskan Native (Person having origins in any of the original peoples of North and South America, including Central America)

Native Hawaiian or Pacific Islander (Person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)

White/Caucasian (Person having origins in any of the peoples of Europe, the Middle East or North Africa)

Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

Asian (Person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, Philippines, Thailand, and Vietnam)

Two or More Races

Please select the option that describes your US citizenship status.

We accept all students, regardless of your answer.

I am a US citizen.

I am a lawfully admitted immigrant.

I prefer not to respond.

Last Grade Completed

Please select the highest level of education you completed.

What is the last year of school you completed?

Where Did you complete most of your previous schooling?

Inside the US

Outside the US

Employment Information

Choose the statement that best describes your employment status.

I am employed full time.

I am employed part time.

I am employed, but my job is being terminated.

I am in the military and will leave the military.

I am unemployed.

I am not working or not able to work, and I am not looking for a job at this time.

ABLE-BODIED ADULT WITHOUT DEPENDENTS

Are you a working adult without dependents who receive SNAP benefits?

Yes

I prefer not to respond.

ACTIVE-DUTY MILITARY SPOUSE

Are you the spouse of an active-duty military personnel?

Yes

I prefer not to respond.

ADULT WITH AGING DEPENDENTS

Are you an adult with the total support responsibility (food, utilities, medical bills, and housing) of an elderly parent or an adult dependent?

Yes

I prefer not to respond.

CAREGIVER

Are you a family member or a paid helper who regularly looks after a child or a sick, elderly, or disabled person?

Yes

I prefer not to respond.

COAL MINING OR SUPPORTING INDUSTRY

Are you a mining machine operator or technician employed in the coal mining or supporting industry?

Yes

I prefer not to respond.

CULTURAL BARRIERS

Do you have attitudes, beliefs, customs, or practices that influence a way of thinking, acting, or working that may make it difficult to find or maintain employment?

Yes

I prefer not to respond.

DISLOCATED WORKER

Have you been terminated, laid off or received a notice of termination or layoff, or have you been notified of a permanent closure of a facility where you are (or were) employed?

Yes

I prefer not to respond.

DISPLACED HOMEMAKER

Were you once a stay-at-home mom or dad, dependent on the income of another, but you are no longer supported by that income and having trouble getting or keeping a job?

Yes

I prefer not to respond.

ENGLISH LANGUAGE LEARNER:

Are you an English Language Learner?

Yes

I prefer not to answer.

EX-OFFENDER

Have you been arrested or required to appear in court for a criminal offense, and you are NOT currently incarcerated?

Please note that a YES answer will not prevent you from receiving services from us.

Yes

I prefer not to respond.

EXHAUSTING TANF WITHIN 2 YEARS

Are you within two years of exhausting lifetime eligibility of Temporary Assistance for Needy Families (TANF)?

Yes

I prefer not to respond.

FIRST GENERATION COLLEGE STUDENT

Are you a college student whose parent(s) did NOT complete a four-year college or university degree?

Yes

I prefer not to respond.

FORMERLY INCARCERATED

Have you ever lived in a correctional facility, including a jail, prison, work release center, or detention center?

Yes

I prefer not to respond.

HOMELESS/RUNAWAY YOUTH

Are you without a fixed, regular, and adequate nighttime residence, or have you moved in the last 36 months due to a parent’s employment in seasonal farm work, or are you under 18 and left home without parent permission?

Yes

I prefer not to respond.

INDIVIDUAL WITH DISABILITIES

Do you have a physical or mental impairment that substantially limits one or more of the person's major life activities?

Yes

I prefer not to respond.

IN NEED OF SUPPORT SERVICES

Do you need help with getting a driver’s license, a social security number, transportation, childcare, food, or housing?

Yes

I prefer not to respond.

LONG-TERM UNEMPLOYED

Have you been out of work and actively seeking employment for at least a year?

Yes

I prefer not to respond.

LOW INCOME

Are you eligible to receive SNAP, TANF, SSI or local public assistance?

Yes

I prefer not to respond.

MIGRANT/SEASONAL WORKER

Have you spent 12 consecutive months out of the last 24 months in agricultural or fish farming labor, or are you a dependent of a seasonal or migrant farmworker without a permanent residence?

Yes

I prefer not to respond.

NON-TRADITIONAL OCCUPATION

Do you currently have an occupation in which your gender comprises less than 25% of the workforce?

Yes

I prefer not to respond.

PARENT OF CHILDREN AGING OUT OF SOCIAL SECURITY

Are you a parent of a child who is near the age of being no longer eligible for Social Security benefits?

Yes

I prefer not to respond.

PREPARING FOR A NON-TRADITIONAL FIELD

Are you preparing for an occupation in which your gender comprises less than 25% of the workforce?

Yes

I prefer not to respond.

SINGLE PARENTS, INCLUDING SINGLE PREGNANT WOMEN

Are you single, separated, divorced, or widowed and have the primary responsibility for one or more dependent children under the age of 18, or are you a single, pregnant woman?

Yes

I prefer not to respond.

SNAP RECIPIENT

Are you eligible for SNAP (Supplemental Nutrition Assistance Program) benefits, which are provided to eligible low-income households to help them buy the food they need for good health?

Yes

I prefer not to respond.

SPECIFIC LEARNING DISABILITY

Are you a learner with a history of educational efforts who has learning impairments in defined limited learning areas, including dyslexia (reading disability), dysgraphia (writing disability), and dyscalculia (math disability)?

Yes

I prefer not to respond.

TANF RECIPIENT

Are you a recipient of TANF (Temporary Assistance for Needy Families), temporary income assistance and related support services for persons who are unemployed or underemployed and have a low income. To qualify you must also:

Have a child 18 years of age or younger, or
Be pregnant, or
Be 18 years of age or younger and the head of your household.

Yes

I prefer not to respond.

UNDEREMPLOYED

Are you working but you not have enough paid work, or are you not doing work that makes full use of your skills and abilities?

Yes

I prefer not to respond.

UNEMPLOYED OR UNDEREMPLOYED

Are you currently unemployed, or do you not have enough paid work, or your are not doing work that makes full use of your skills and abilities?

Yes

I prefer not to respond.

VETERAN

Did you serve in the military, naval, or air service and discharged or released under conditions other than dishonorable?

Yes

I prefer not to respond.

YOUTH/YOUNG ADULT IN OR AGED OUT OF FOSTER CARE

Are you aged 16-24 and currently in the foster care system or were you previously in the foster care system?

Yes

I prefer not to respond.

YOUTH WITH PARENTS IN ACTIVE-DUTY MILITARY

Are you aged 16-24 and currently under the care of a parent or guardian who is active-duty military?

Yes

I prefer not to respond.

What is the primary goal(s) you would like to accomplish with us?

Select all that apply.

Improve my basic academic skills.

Earn a US High School Equivalency (HSE) diploma.

Enter employment.

Retain my employment.

Enroll in career-related training.

Enroll in postsecondary education (college/university).

Become a citizen of the US.

Increase my involvement with my child’s education and literacy.

If you have any other goals or needs, please type those here, as well as anything else you would like our staff to know about you.

DATA EXCHANGE PERMISSION

By checking this box, the applicant hereby provides permission for his/her data to be exchanged with other education, state, and workforce agencies for the purpose of verifying outcomes, performance, and credentials related to postsecondary education/training and employment or other services that are provided by Adult Education

Yes, I agree to the Release of Information described above.

Electronic Student Signature.

Please type your full legal name, as this will serve as your electronic signature. This signature acknowledges that the information provided in this form is correct and that you agree to the releases contained in this registration form.

Date

Student Information

LANGUAGE

Employment Information

DATA EXCHANGE PERMISSION

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