2018-19 Wayne Adult Ed Student Registration

STUDENT INFORMATION
ACADEMIC YEAR 2018-19
I am enrolling in the following program:*
- ELL (English Language Learning) classes - I need to learn English.
- ABE (Adult Basic Education) / HSE (High School Equivalency) classes - I need a High School Equivalency OR I already have a diploma, but am seeking career training.
Name*
First Middle Last
Have you ever attended an ELL (English Language Learning) program before?*
- Yes
- No
What was the name of the school?*
In what year were you enrolled in the ELL (English Language Learning) program?*
Have you ever attended an ABE (Adult Basic Education) or HSE (High School Equivalency) program before?*
- Yes
- No
What was the name of the program?*
In what year were you enrolled in the ABE (Adult Basic Education) or HSE (High School Equivalency) program?*
Student Information
Address*
Street Address City State ZIP Code
Do you have a home phone?*
- Yes
- No
Home Phone Number*
Do you have a mobile phone?*
- Yes
- No
Mobile Phone Number*
Do you prefer to be contacted via text message?*
- Yes
- No
Do you have an email address?*
- Yes
- No
Email Address:*
Make this an email you check often.
I live in:*
- Marion County
- Hendricks County
- Morgan County

EMERGENCY CONTACT INFORMATION
Emergency Contact's Name*
First Last
Emergency Contact's Phone*
Relationship to you:*
- Spouse/Significant Other
- Parent
- Legal Guardian
- Other family member
- Friend

Employment Information
Employment Status: (Choose the one that BEST describes you.)*
- Employed
- Unemployed
- Not working, not looking for a job, not in the labor force
- Employed, termination/separation pending
- Unemployed more than 26 weeks
Employer Name:*
Date hired:*

Release of Information
I am enrolled in an adult education (AE) program. This AE program works with the following programs and agencies to help students improve their skills and earn better jobs:
• Other state-funded adult education programs
• WorkOne offices and job training programs
• Public and private colleges
• State executive offices, departments, and agencies including the Indiana Department of Workforce Development (DWD), Division of Adult Education and the Indiana Department of Education.

By signing below, I understand and agree to the following:
• The information on my intake form is correct.
• DWD use of directory information (name, address, birth, and social security number) to match test score records, wage information, and college/training program enrollment records that assist the state to evaluate and improve its programs and to report results to the federal and state government.
• The sharing of information between the agencies and programs listed above. This information may include my name, enrollment information, education/career goals, test scores, and employment history. The information will be kept strictly confidential and will be used for program administration, research, and evaluation purposes.
I agree to the above information*
- Yes
Signature*
Please type your full name.
Code of Conduct
I have read, and I agree to abide by, the rules in the Wayne Township Adult Education Code of Conduct. Furthermore, I know how to access the Wayne Township Adult Education Student Handbook for future reference.
I agree to the above information*
- Yes
Signature*
Please type your full name.
Photo Release
I give permission for Wayne Township Adult Education to use my photo on online or print promotional communication.
I agree to the above information*
- Yes
- No
Signature*
Please type your full name.

Step 1 of 8 - Background

STUDENT INFORMATION

Student Information

EMERGENCY CONTACT INFORMATION

Student Information

Employment Information

Educational Information

Required for State Funding

Required for State Funding

Required for State Funding

Required for State Funding

Release of Information

Code of Conduct

Photo Release