VRABE Regional Adult Based Education

Adult Education Student Information Form

Please fill out the form: (* denotes required fields)
Last Name *
 First Name * (as it appears on your ID)
Middle Name
 Suffix
Nickname (Name you preferred to be called, if different)
SASID
 Residence Area
Country Born *
 Social Security # *
Native Language *
Gender *
 Birthdate *
Ethnicity * (must select at least one)
 Race * (must select at least one)
Highest Education Level Location *
Highest Education Level Completed on Entry: *
Write in the grade level:*
Write in the grade level:* Last High School Attended:*
Write in the grade level:* Last Secondary School Attended:*
Write in the grade level:* Last Post-Secondary School Attended:*
Write in the grade level:* Last Post-Secondary School Attended:*
Employment Status *
Name of Employer*
Employer Phone*
Miscellaneous Characteristics
(Check all that apply)
WIOA Core Programs *
(Check all that apply)
 School Equipment
(ADD Which of the following do you have at home so we can contact you and/or connect you to services?)
Home Street Address *
 City *
State *
 Zip Code *
Email Address *
Phone Number *
Parent/Guardian of: * (Check all that apply and list number)
If yes, how many?
If yes, how many?
If yes, how many?

Emergency Contact Information

Name of Emergency Contact *
 Emergency Telephone *

All Students Must Check One Category Below: *

Low-level Literacy
ABE, GED, NEDP, CDP students
(All students who do not have an SSD at entry)
 English Language Learner/Cultural Barriers
ESL/ELL students

Why Are You Enrolling In Adult Education? Check All That Apply *

Do You Have Barriers to Employment? Check All That Apply Below: *

Cultural Barriers
Do you feel your culture, beliefs, or practices makes finding/keeping a job harder?
Disabled
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
Do you have low income?
English Language Learner
Are you an English Language Learner?
Ex Offender
Do you have a criminal record that makes it hard to find a job? (Do not select this category if you are currently incarcerated)
7. 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 Youth
Are/were you in the foster care system and are under 24 years old?
Homeless
Are you homeless? Do you lack a regular and adequate residence? 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 Literacy Levels
Are your literacy levels low?
Migrant and Seasonal Farmworker
(if yes, select a subcategory)
Single Parent or Guardian
Are you a single parent, unmarried or separated and have primary responsibility for one or more children under age 18?

Computer Acceptable Use Policy

I agree to take personal responsibility for following the rules of the acceptable use policy stated in this contract. I will:

  • Use the on-line resources provided by my school ONLY for school-sanctioned projects.
  • Use the on-line resources provided by my school ONLY with the permission of a teacher or library media specialist.
  • Use language on-line which is consistent with school policy.
  • Not tamper with equipment or software; nor alter the network interface; nor attempt to gain access to the data and files of others; nor attempt to access information on the Internet, or other online services, not consistent with the educational goals of the school; nor violate any copyright laws.
  • Report any problems or breaches of this agreement to a teacher.
  • Not use the Internet inappropriately and understand that if I do, my behavior will result in:
    1. Losing all on-line privileges within the school setting.
    2. Being subjected to disciplinary measures under Vernon Regional Adult Based Education Policy, Board of Education Policy, and/or being referred to the appropriate legal authorities, if warranted.

How Did You Hear About Us (Check All That Apply)? *


Please specify:*

Waiver *

Vernon Regional Adult Based Education (VRABE) (Choose one) my permission to use my photograph, video and audio recordings, likeness, artwork, profile and/or story in this and future publications, web pages and other promotional materials produced, used by, and representing VRABE.

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

Applicant Signature *
 Date *