• 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 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

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

Electronic Signature

Signature (Please type your name) *

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