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 
Program Option(s) *  
Social Security Number
Last Name *
First Name *
Middle Name
Suffix 
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 
Country You Were Born In
Date of Birth
Gender 
Ethnicity 
Race 
Select all that apply. 
How did you hear about Adult Education?

Education Information

Highest Education Level Completed 
Grade Level Completed
(If Elementary or High School selected above)
Last High School Attended
Highest Educational Level Location 
Low-Level Literacy
(ABE, GED, NEDP, CDP students; all students who do not have a Secondary School Diploma at entry) 
English Language Learners / Cultural Barriers
(ESL / ELL students) 

WIOA Core Programs

WIOA Core Programs - please select one or more *  
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 
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) 
# 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.) 
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)? 
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? 
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? 
Displaced Homemaker
Are you a former homemaker who is having trouble finding a job or a better job? 
Dislocated Worker
Have you been fired or laid off? Are you unemployed because the place where you worked has closed? 
Disabled
Do you wish to disclose any disability that limits your life activities? 

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) 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. By signing this form, I give permission to the Connecticut State Department of Education to share my data. 


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Windsor Public Schools

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

Ed2Go Learn 2 Earn
COABE Educate and Elecate