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
Nickname (Name you preferred to be called, if different)
Residence Area
Country Born *
Birthdate *
Gender *
Social Security #
Ethnicity * (must select at least one)
Race * (must select at least one)
Highest Education Level Completed on Entry:  *
Write in the grade level:*
Write in the grade level:*
Last High School Attended *
Highest Education Level Location *
Employment Status *
Name of Employer *

Address of Employer
WIOA Core Programs
(Check all that apply)
Start Date:*
Start Date:*
Start Date:*
Start Date:*
Start Date:*
Miscellaneous Characteristics
(Check all that apply)
Home Street Address *
Zip Code *
City *
County *
State *
Email Address *
Phone Number * (fill in at least one)
Which is your contact preference? *
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 #1 *
Relationship *
Address *
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:

1. Cultural Barriers
Do you feel your culture, beliefs, or practices makes finding/keeping a job harder?
2. Disabled
Do you wish to disclose any disability that limits your life activities?
3. Displaced Homemaker
Are you a former homemaker who is having trouble finding a job or a better job?
4. Low Income
Do you have a low income? Do you receive SNAP, TANF, SSI, or local public assistance? Are you a foster child or homeless?
5. English Language Learner
Are you an English Language Learner?
6. 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?
8. Foster Care Youth
Are/were you in the foster care system and are under 24 years old?
9. 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?
10. Long-Term Unemployed
Have you been unemployed for 27 or more weeks (more than 6 months)?
11. Low Literacy Levels
Are your literacy levels low?
12. Migrant and Seasonal Farmworker
(if yes, select a subcategory)
13. Single Parent or Guardian (or single pregnant woman)
Are you a single parent, unmarried or separated and have primary responsibility for one or more children under age 18, or are you a single, pregnant woman?

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 *