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)
 Residence Area
Country Born *
 Social Security # *
Native Language *
 Birthdate *
Sex *
 Gender Identity
Pronouns
 WIOA Core Programs *
(Check all that apply)
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*
Start Date of Job:
 Pay Frequency:
Earnings Amount:
This information does not affect the eligibility of students to receive a free education as provided by the VRABE. It is solely intended for program funding purposes to ensure each student can access a free education.
Miscellaneous Characteristics
(Check all that apply)
Equipment (Select all that apply)
(ADD Which of the following do you have at home so we can contact you and/or connect you to services?)
Home Street Address *
 Ste/Unit
City *
State *
 Zip Code *
Email Address *
 Secondary Address
Phone Number *
Parent/Guardian of: * (Check the box that applies. If selected, enter the number of children in the field that appears.)

Emergency Contact Information

Name of Emergency Contact *
 Emergency Telephone *

Why Are You Enrolling In Adult Education? (Choose One) *

Please specify:*

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?
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?
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 Farmworker *
Seasonal Farmworker *
Single Parent or Guardian *
Are you a single parent, unmarried or separated and have primary responsibility for one or more children under age 18?

Acceptable Technology Use Policy

I agree to follow these rules for using school resources responsibly:

  • Use online resources only for school-approved projects.
  • Access online resources only with a teacher's or media specialist's permission.
  • Use language that aligns with school policies.
  • Do not tamper with equipment, software, or network settings, attempt to access others' data, or view non-educational content.
  • Report any issues or policy breaches to a teacher.

If I misuse the internet, I understand that:

  • I may lose all online privileges within the school.
  • Students are required to return all borrowed equipment, including laptops, to VRABE upon completion of the program or within two weeks of exiting, to avoid forfeiting their deposit or further action.
  • Disciplinary action may be taken under Vernon Regional Adult Education or Board of Education policies, or referred to legal authorities if necessary.

How Did You Hear About Us? *

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 *

Acceptable Technology/Phone Use & Data Acknowledgment