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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 *  
Program Option(s) *  
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 *  
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 
Gender Identity
Country You Were Born In *
Language Spoken at Home *
Ethnicity *  
Race *  

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? 
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? 
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)? 
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?  
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? 
Title IV Vocational Rehabilitation Start Date

Education Information

Highest Education Level Completed *
Highest Educational Level Location *  
Last School Attended *

Employment Information

Employment Status *  
Name of Employer
How did you hear about Adult Education? *
Why are you enrolling in Adult Education? Check all that apply. *  
'Other' Why Enroll (if checked above)

Contact Information

Home Street Address *
City *
Zip Code *
State *
Phone Number *
Phone Type *  
Alternate Number
Phone Type 
Email Address *
Contact Preference 
Emergency Contact Name *
Emergency Contact Phone # *
Emergency Contact Relation

Barriers to Education

English Language Learners / Cultural Barriers
(ESL / ELL students) *  
Do you wish to disclose any disability that limits your life activities? *  
Displaced Homemaker
Are you a former homemaker who is having trouble finding a job or a better job? *  
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? *  
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.) *  
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? *  
Youth in Foster Care / Aged Out
Are/were you in the foster care system AND are under 24 years old? *  
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? *  
Long-Term Unemployed
Have you been unemployed for 27 or more weeks (more than 6 months)? *  
Low-Level Literacy
(ABE, GED, NEDP, CDP students; all students who do not have a Secondary School Diploma at entry) *  
Migrant and Seasonal Farmworker
Are you... (select one) *  
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? *  
Dislocated Worker
Have you been fired or laid off? Are you unemployed because the place where you worked has closed? *  

Miscellaneous Characteristics

Select all that apply to you *  
Which of the following do you have at home? Select all that apply *  

Family Information

Are you the parent or guardian of...
(Select all that apply) *  
# 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 (GEDŽ) 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. *  

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 *  
*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. *  

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Windsor Public Schools

601 Matianuck Ave
Windsor, CT 06095
Tel: 860.687.2000 ext. 1273

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