2021-22 Learner Registration Form STUDENT INFORMATIONPROGRAM YEAR 2021-22Name*Please carefully type your legal name. First Middle Last Social Security Number:We do not require you to provide your social security number, but providing it helps us to track your accomplishments as well as any resources we might be able to provide for you. As always, we keep all of our data secure. Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone Number*We communicate important messages to students via text message. If you do not currently have a mobile phone, please list a phone number of a trusted family member or friend so that you can receive messages.Email:*Enter an email address you can access easily and check frequently. If you do not have an email, click here for instructions on how to create one.. Are you a US Citizen?*We accept ALL students, regardless of which citizenship status you choose. Clicking NO will not prevent you from enrolling with us. Yes No Country of Birth:* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age:*To enroll, a 16 or 17-year-old student must have a signed exit interview from his/her school district upon registration with us. We also need parent or guardian signatures, so parents/guardians need to accompany their 16 or 17-year-old children for registration. Click Here to Download Exit Interview FormTo be able to take the test to earn a High School Equivalency diploma, a 16 or 17-year-old student will also need a Superintendent's Recommendation form signed by his/her school district's Superintendent before he/she can test with us. If you are unable to obtain that Superintendent's signature, let us know and we can help get it completed. Click here to download the Superintendent's Recommendation form.Gender* Male Female Non-Binary ETHNICITY:*NOTE: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race, refers to Hispanic ethnicity. Please select the option below that describes your ethnicity. Hispanic Not Hispanic Race:*Please select all that apply. African American Asian American Indian Pacific Islander White Other Name of Emergency Contact:*Who can we contact if we cannot reach you? First Last Emergency Contact's Phone Number*Employment InformationEmployment Status: (Choose the one that best describes you.)* I am NOT IN THE LABOR FORCE, as I am not working, not able to work, or not looking for a job. I am able to work but am currently NOT EMPLOYED. I am EMPLOYED, BUT MY JOB IS BEING TERMINATED. I am EMPLOYED. Employer:* When were you hired?**You can just give your best estimate if you do not remember the exact date.Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer Phone:*Educational InformationEducational Status:*Please check the highest level of education you have completed. No schooling Grades 1-5 Grades 6-8 Grades 9-12 (no diploma) High School Certificate (Disability/IEP) High School Diploma HSE (High School Equivalency) / GED Some college or career training beyond high school (no degree) Professional License/Career Certificate (no college degree) College degree (Associate's Degree) College degree (Bachelor's Degree) College degree (Beyond Bachelor's Degree) Unknown Last Grade Completed*Please list the last grade level (1-12) that you completed. *If you have completed education beyond high school, you can list "12+" as your last grade level completed. Last School Attended:*Please type the name of the last school you attended. Previous Schooling Location:*Where did you complete most of your schooling so far? U.S.-based schools Non-U.S.-based schools School Attendance Status at Entry:*Select the option that BEST describes your current school situation: In-school: Grades k-12 In-school: Alternative School In-school: Postsecondary (beyond 12th grade) Not attending school: 18 or older and did not not finish high school Not attending school: Earned high school diploma or equivalent Not attending school - Under 18 years old and did not finish high school Household InformationAnnual Family Income (yearly income before taxes):*We are asking this information for the purpose of finding resources for you. We accept all students, regardless of family income.Household Size*How many people live in your household, including yourself?Current Enrollment Type:*For which reason are you interested in coming to school? Choose ELL to learn English, or choose ABE for everything else. I want to learn English. I want to improve my academic skills to prepare for career training or earn a High School Equivalency (HSE) diploma. Residential Institution:*Please select the option that describes your residential situation. Correctional Facility Community Corrections Facility Medical Facility/Group Home/Nursing Home None of these apply to me. Method Found:*How did you learn about us? TV/Radio Newspaper Brochure/Flyer Department of Workforce Development Public Assistance Referral Literacy Program Referral Court Referral Other Referral Employer Shelter School Website DWD Website Signage in Community DemographicsCheck any of the following that apply to you:* I have some impairments (Physical, Mental, or Learning). I live in an urban area. (I live in the city; Housing, businesses, and shopping are close to me.) I live in a rural area. ( I live outside of the city, far away from housing, businesses, and shopping.) I receive public assistance. (SSI, SNAP, TANF, WIC, etc) I have a low income. I am a displaced homemaker. (I was a homemaker but now have to enter the workforce due to a change in circumstance). I am a single parent. I am a dislocated worker. (I lost my job due to my employer moving locations.) I am a dependent, or I have dependent(s). I am a foster care youth (age 16-24 and either in foster care or aged-out of it). I am homeless or a runaway. I speak a language other than English at home. As adults, we sometimes have barriers that make coming to school more difficult. Do you need help with any of these barriers?Check all that apply: Transportation Child care Feeding my family Immigration / citizenship information Legal help Medical care Testing accommodations I don’t have any of these barriers at this time. What is the language you first learned as a child?* Migrant/Seasonal Farm Worker:*Please select the option that best describes you: This does not apply to me. Migrant Worker Migrant and Seasonal Worker Dependent of a Migrant/Seasonal Worker Active Military:*Please select the option that best describes you: This does not apply to me. I am active military. I am the spouse of active military. Are you involved in a Vocational Rehabilitation agency?*Please select the option that best describes you. No Yes VR & E Both VE and VR & E Unknown Wagner Peyser Employment*Wagner-Peyser employment refers to a federally-funded program that connects employers with job seekers. Yes No Unknown Ex-Offender*Have you ever been convicted of a crime? Yes No Unknown Cultural Barriers to Employment*Do you have any cultural barriers that affect your job opportunities? Yes No Unknown Release of InformationI am enrolling in an Adult Basic Education (ABE) program. This ABE 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 (IDWD), 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 Release of Information described above.* Yes Photo ReleaseWe love to celebrate success with our students, and we often do that through pictures, articles, slideshows, and other fun media. In order for you to participate in that, we will need permission to use your photo.I grant to MSD of Warren Township Adult Education, its representatives and employees the right to take and/or use provided photographs of me in connection with documents and promotional materials published by the same. I authorize MSD of Warren Township Adult Education, its representatives and employees, to use and publish the same in print and/or electronically. I agree that MSD of Warren Township Adult Education may use such photographs of me with or without my name for purposes including training and instruction manuals, promotional materials, and electronic documents. Student Photo Release* I agree to the above photo release statement. I do not agree to the above photo release statement. Student Contract/Code of ConductPlease review our Student Contract that can be found at the following link. The link will open in a new tab, so please make sure to come back to this tab to finish signing this form. warrenadulted.com/student-contractStudent Contract Agreement*I have read, and I agree to abide by, the rules in the MSD of Warren Township Adult Education Student Contract, which can be found at warrenadulteducation.com/student-contract for current and future reference. Yes Enrollment Verification RequestPlease let us know if you need verification of your school enrollment.Will you need a letter of enrollment verification sent to another agency?* Yes No You may request a letter of enrollment verification be sent to other agencies under the following conditions: ✓ you have at least 12 hours of attendance ✓ you understand that MSD Warren Township Adult Education staff members needs 2-3 business days to process this request ✓ you give permission for Warren Township Adult Education to share this information ✓ you provide the contact information requested below Agency Name:* Agency Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Agency Phone*Agency Email* Contact Name* First Last Electronic SignatureTyping your name in the fields below will constitute your electronic signature(s) for the above provided information. Please verify that all information is accurate before you sign. Applicants who are under 18 years of age will require a parent/guardian signature as well.Signature*Please type your full name, as this will serve as your electronic signature. This signature acknowledges that the information provided in this form is correct. Parent/Guardian Signature*Parent/Guardian, please type your full name, as this will serve as your electronic signature. This signature acknowledges that the information provided in this form is correct.