Windsor Adult Education Student Registration Information Form

All student information is confidential and will only be used for program administration, research, and evaluation purposes. Please arrive at least 5-10 minutes before your scheduled test(s) appointments.

To provide proof of identity and residency, please bring a valid and current State of CT photo identification such as a valid driver's license/permit or a utility bill that is no older than 90 days.

Tuition is free for Windsor Residents. Non-residents please bring $10/semester on day of the test. 

Contact the office at 860.687.2000 x1271 to reschedule if you are unable to make your test(s) appointment(s).

Please remember to make a note of your test date & time.

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(* Denotes Required Fields)

Personal Information

Student Type *   Returning Student New Student Program Option(s) *   English as a Second Language (ESL) (9:00 AM - 11:30 AM) English as a Second Language (ESL) (6:00 PM - 8:30 PM) High School Completion (GED®) (9:00 AM - 11:30 AM) High School Completion (GED®) (6:00 PM -- 8:30 PM) Adult Basic Education (ABE) (Noon - 2:30 PM) Adult Basic Education (ABE) (6:00 PM - 8:30 PM) Citizenship (6:00 PM - 8:30 PM) NEDP Social Security Number Last Name (as it appears on your ID) * First Name (as it appears on your ID) * Middle Name Date of Birth * Sex *   Male Female Other Suffix  Jr. Sr. Preferred Name SASID # (State Assigned Student Identification Number) (If you are 17 or 18 years old, this number must be provided, as well as your Official High School Withdrawal Form) Residence Area  Rural Urban Gender Identity Gender FluidGender NonconformingGender QueerManNonbinaryOtherPrefer Not To DiscloseTransgenderTwo-SpiritWoman Pronoun (f)aee/eyhepershetheyvexeze Country You Were Born In * Language Spoken at Home * Ethnicity *   Hispanic or Latino Not Hispanic or Latino Race *   American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

WIOA Core Programs

The Workforce Innovation and Opportunity Act (WIOA) provides services for eligible adults. The American Job Center (AJC) may use WIOA Adult funds to provide individualized career services and training services. WIOA Core Programs - please select one or more if you participate in a WIOA Program.  Title I Adult Do you receive individualized services through the AJC? Receive regular career counseling (group or individual) assigned worker appointments? Enrolled in training (for age 24 +) paid for by the AJC?  Yes No Title I Adult Start Date Title 1 Dislocated Worker Do you receive unemployment benefits? Identify as a dislocated worker or trying to return to work from previously working as a homemaker?  Yes No Title I Dislocated Worker Start Date Title I Youth Are you currently an in-school or out-of-school youth who is out and receiving services from your local American Job Center (AJC)?  Yes No Title I Youth Start Date Title III Wagner-Peyser Are you currently registered with your local AJC? Do you currently utilize your local AJC for workshops and the self-serve computer access?   Yes No Title III Wagner-Peyser Start Date Title IV Vocational Rehabilitation Are you currently working with the Bureau of Rehabilitation Services (BRS) to find employment? Do you have a disability that impacts your ability to obtain and maintain employment? Do you have an employment plan with the state vocational rehabilitation agency/BRS/BESB?  Yes No Title IV Vocational Rehabilitation Start Date

Education Information

Highest Education Level Completed * No Schooling1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade - No Diploma9th Grade - No Diploma10th Grade - No Diploma11th Grade - No Diploma12th Grade - No DiplomaSecondary School Diploma or alternateCredentialUnknownSecondary School EquivalentSome Postsecondary education, no DegreePostsecondary or Professional Degree Highest Educational Level Location *   United States-based schooling Non-United States-based schooling Last School Attended *

Employment Information

Employment Status *   Employed, Full-Time Employed, Part-Time Unemployed Not looking for work Unavailable for work Retired Employed With Separation Notice Name of Employer How did you hear about Adult Education? * Local Job ServicesJob-training programOne-Stop CenterCommunity Action AgencyHRDFOICDivision of Rehab ServicesDHHRCollegeNewspaper adPamphlet. Brochure, PosterFriendEmployerHigh SchoolFamily MemberTelevision/RadioI Attended BeforeAdult Education HotlineOther Why are you enrolling in Adult Education? Check all that apply. *   Improve Job Prospects Improve English Obtain Driver's License Obtain Citizenship Get Diploma or Certificate Qualify for Training/Military Help My Children Social / Improve Skills Qualify For College Required To Attend Improve Reading Skills Improve Math Skills Other 'Other' Why Enroll (if checked above)

Contact Information

Home Street Address * City * Zip Code * County State * Phone Number * Phone Type *   Cell Home Alternate Number Phone Type  Cell Home Work Email Address * Contact Preference  Any phone or time Home only Work only Mobile only Emergency Contact Name * Emergency Contact Phone # * Emergency Contact Relation SpouseParentSiblingFriendChildCo-WorkerOther

Barriers to Education

English Language Learners / Cultural Barriers (ESL / ELL students) *   Yes No Disabled Do you wish to disclose any disability that limits your life activities? *   Yes No Displaced Homemaker Are you a former homemaker who is having trouble finding a job or a better job? *   Yes No 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? *   Yes No Ex-Offender Do you have a criminal record that makes it hard for you to find a job? (Do not choose "yes" if you are currently incarcerated.) *   Yes No 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? *   Yes No Youth in Foster Care / Aged Out Are/were you in the foster care system AND are under 24 years old? *   Yes No Homeless or Runaway Youth Are you homeless? Do you live in a motel, hotel, campground, transitional housing or with another person because you lost your house or apartment? *   Yes No Long-Term Unemployed Have you been unemployed for 27 or more weeks (more than 6 months)? *   Yes No Low-Level Literacy (ABE, GED, NEDP, CDP students; all students who do not have a Secondary School Diploma at entry) *   Yes No Migrant and Seasonal Farmworker Are you... (select one) *   A seasonal farmworker who has worked in the last 12 months in agriculture, fish or on a farm A seasonal worker with no permanent residence (migrant) The dependent of a farmworker None of the above Single Parent (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? *   Yes No Dislocated Worker Have you been fired or laid off? Are you unemployed because the place where you worked has closed? *   Yes No

Miscellaneous Characteristics

Select all that apply to you *   Receive public assistance Immigrant Community / Alt. corrections Mother under 17 - C.G.S.10-73d Needs child / dependent care None of the above Which of the following do you have at home? Select all that apply *   Computer with Camera Computer without Camera Webcam Headset with Microphone Mobile Phone Home Phone Internet Access Printer Scanner

Family Information

Are you the parent or guardian of... (Select all that apply) *   Child(ren) 5 years old & younger Child(ren) 6 - 10 years old Child(ren) 11 - 18 years old No child(ren) or child(ren) 18 years and older # of child(ren) 5 years old & younger # of child(ren) 6 - 10 years old # of child(ren) 11-18 years old

Exam Dates & Times

If you are registering for English as a second Language (ESL) and/or Citizenship classes, you are required to take a Reading test for proper class placement. This will take approximately one hour to complete. If you are registering for High School Completion (GED®) or ABE classes, you are required to take a Reading and Math test for proper class placement. This will take approximately two hours to complete and can be done in one testing session or two. If you prefer two sessions, please indicate. *   I am exempt from testing because I have tested within the last 30 days. I understand that this is subject to program review. Wednesday January 18, 2023 at 9am Wednesday January 18, 2023 at 12pm Wednesday January 18, 2023 at 6pm Thursday January 19, 2023 at 9am Thursday January 19, 2023 at 12pm Monday January 23, 2023 at 9am Monday January 23, 2023 at 12pm Tuesday January 24, 2023 at 9am Tuesday January 24, 2023 at 12pm Wednesday January 25, 2023 at 9am Wednesday January 25, 2023 at 12pm Wednesday January 25, 2023 at 6pm Thursday February 2, 2023 at 9am Thursday February 2, 2023 at 6pm

Electronic Signature

Signature (Please type your name) * *Data matching is used to improve program performances and serve students. The data will be compiled to find out how well adult education programs are performing throughout the country and to improve Windsor's program services. All information will be kept confidential and NO NAMES, OR OTHER IDENTIFYING INFORMATION will be associated with your data. Please check a box *   Yes, I am willing to be included in data matching for the benefit of Windsor Adult Education. No, I prefer not to be included and will participate in frequent phone interviews after I exit Windsor Adult Education. *I give permission for Windsor Adult Education to use my photograph, likeness, video and audio, artwork and /or story in publications, web pages or other materials produced, used by and representing Windsor Adult Education. *   I agree I do not agree

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