• Windsor Adult Education Student Information Form

Windsor Adult Education Student Information Form

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

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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) Adult Basic Education (ABE) (Noon - 2:30 PM) High School Completion (GED®) (6:00 PM -- 8:30 PM) Citizenship (6:00 PM - 8:30 PM) Social Security Number Last Name * First Name * Middle Name Suffix  Jr. Sr. 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 Country You Were Born In Date of Birth Gender  Male Female 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 Select all that apply.  Receive public assistance Immigrant Community / Alt. corrections Mother under 17 - C.G.S.10-73d Needs child / dependent care Needs transportation How did you hear about Adult Education?

Education Information

Highest Education Level Completed  No schooling Elementary High school Secondary School Diploma Some Post-Secondary / Post-Secondary Degree Grade Level Completed (If Elementary or High School selected above) Last High School Attended Highest Educational Level Location  United States-based schooling Non-United States-based schooling Low-Level Literacy (ABE, GED, NEDP, CDP students; all students who do not have a Secondary School Diploma at entry)  Yes No English Language Learners / Cultural Barriers (ESL / ELL students)  Yes No

WIOA Core Programs

WIOA Core Programs - please select one or more *   Title I Adult Title I Dislocated Worker Title I Youth Title III Wagner-Peyser Title IV Vocational Rehabilitation Title I Adult Start Date Title I Dislocated Worker Start Date Title I Youth Start Date Title III Wagner-Peyser Start Date Title IV Vocational Rehabilitation Start Date

Employment Information

Employment Status  Employed, Full-Time Employed, Part-Time Unemployed Not looking for work Unavailable for work Retired Unemployed with separation notice Name of Employer

Contact Information

Home Street Address City County Zip Code State Phone * Alternate Phone Email Address * Emergency Contact Name Emergency Contact Phone #

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 # of child(ren) 5 years old & younger # of child(ren) 6 - 10 years old # of child(ren) 11-18 years old

Demographic Information

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 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 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 Displaced Homemaker Are you a former homemaker who is having trouble finding a job or a better job?  Yes No Dislocated Worker Have you been fired or laid off? Are you unemployed because the place where you worked has closed?  Yes No Disabled Do you wish to disclose any disability that limits your life activities?  Yes No

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®) 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. Tuesday January 11 at 9am Tuesday January 11 at 11am Tuesday January 11 at 1pm Wednesday January 12 at 9am Wednesday January 12 at 11am Wednesday January 12 at 1pm Wednesday January 12 at 6pm Thursday January 13 at 9am Thursday January 13 at 11am Thursday January 13 at 1pm Friday January 14 at 9am Friday January 14 at 11am Friday January 14 at 1pm Tuesday January 18 at 9am Tuesday January 18 at 11am Tuesday January 18 at 1pm Wednesday January 19 at 9am Wednesday January 19 at 11am Wednesday January 19 at 1pm Wednesday January 19 at 6pm Thursday January 20 at 9am Thursday January 20 at 11am Thursday January 20 at 1pm Friday January 21 at 9am Friday January 21 at 11am Friday January 21 at 1pm Monday January 24 at 9am Monday January 24 at 11am Monday January 24 at 1pm Tuesday January 25 at 9am Tuesday January 25 at 11am Tuesday January 25 at 1pm Wednesday January 26 at 9am Wednesday January 26 at 11am Wednesday January 26 at 1pm Wednesday January 26 at 6pm

Electronic Signature

Signature (Please type your name) * *Data matching is used to improve program performances and serve students. By signing this form, I give permission to the Connecticut State Department of Education to share my data.  Check this box to opt out of State agency data matching.

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