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 *
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?
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?
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 *