Adult Education Enrollment Form

Please fill out the form: ( denotes required fields)*

Student Type: * Returning Student New Student
Intake Date	SSN
Last Name *	First Name * (as it appears on your ID)
Middle Name	Suffix
Preferred Name

Home Street Address *
Zip Code *	City *
County	State *
Email Address *

Phone Number * (fill in at least one)

Home Phone

Mobile Phone

Work Phone

Parent/Guardian of: (Check all that apply and list number)

Child(ren) 5 years and younger	If yes, how many?
Child(ren) 6 to 10 years	If yes, how many?
Child(ren) 11 to 18 years	If yes, how many?

Emergency Contact Information

Name of Emergency Contact *

Emergency Telephone *

Employer

Name of Employer	Employer Phone
Employer Address

I understand (must select all 4): *

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

I will take all pre/post tests as required.

I will provide a photo I.D. and address verification.

Photo release (select one): *

I agree to have my name or picture/video appear in any Wallingford Adult Education publications.

I do not wish to have my name or picture/video appear in any Wallingford Adult Education publications.

Applicant Signature *

Date *

Data Matching is used to improve Adult Education performance and serve our students. By signing this form, I give permission to the Connecticut State Department of Education to share my data with other agencies.

Check this box to opt in to State Agency Data Matching.

Program * General Educational Development Credit Diploma Program National External Diploma Program English As A Second Language Family Literacy Civics Eat around the world ESL SCOW ESL Cheshire Americanization/Citizenship	Preferred Class Time * Morning Afternoon Evening
SASID	Residence Area Rural Urban
Country Born: *	Birthdate *
Gender * Male Female Other	Pronouns He She They Other
Ethnicity * (check one) Hispanic or Latino Not Hispanic or Latino	Race * (must select at least one) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Highest Education Level Completed on Entry: * No Schooling Elementary Grade Write in the grade level:* High School Grade Write in the grade level:* Secondary School Diploma Some Post-Secondary/Post-Secondary Degree Last High School Attended *	Highest Education Level Location * US-based Schooling Non-US-based Schooling
Employment Status * Employed, Full Time Employed, Part Time Unemployed, seeking employment Not looking for work Unavailable for work Retired Unemployed with Separation Notice	Miscellaneous Characteristics (Check 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? * (Check all that apply) Internet Search Brochure Social Media School Counselor Adult Ed Student Friend/Family Local Job Service Community Agency Other

Adult Education Enrollment Form

Please fill out the form: (* denotes required fields)

Emergency Contact Information

Employer

Please fill out the form: ( denotes required fields)*