Adult Education and Literacy Student Enrollment Form

Basic Information

Last Name:field type single line
Input blocked. Maximum character limit of 4000 characters reached.
First Name:field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Middle Name:field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Date of Birthfield type date
Genderfield type drop-down
Phone Numberfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email Addressfield type email
Social Security Numberfield type single line
Input blocked. Maximum character limit of 11 characters reached.
Texas Driver's License or ID Numberfield type single line
Input blocked. Maximum character limit of 9 characters reached.
Addressfield type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Ethnicityfield type checkbox
EthnicityHispanicNot Hispanic
Racefield type checkbox
RaceAmerican Indian/Alaska NativeAsianBlack African AmericanNative Hawaiian or PacificWhite

Release of Information and Permission to Participate in the Program

The information provided is complete and correct to the best of my knowledge. I agree to abide by Adult Education Program policies, rules and regulations. I further understand the submission of false information is grounds for rejection of my application, withdrawal of acceptance, and cancellation of enrollment. Texas Workforce Commission (TWC) regulations and Adult Education Program internal policies are used to aggregate statistical data in evaluation of the program and shall constitute a precondition for enrollment into adult education and literacy program, followup, tracking, and to generate reports to monitor the program. My signature below shall constitute acknowledgement to statistical use of my records of enrollment, progress, credential obtainment, and transition to post-secondary enrollment or employment. My signature below also authorizes use of my personally identifiable information, including my employment and wage information pre-, during and post-enrollment for audit, study and evaluation of the Adult Education and Literacy program performance and other state and federally-funded programs. Such programs may include but are not limited to those under the laws, administered by the Texas Education Agency and the Texas Higher Education Coordinating Board. I acknowledge that the Adult Education and Literacy program and that TWC may release personal identifiable information to other local, federal, partners and/or stakeholders. This includes eligible training Providers regarding all assessments taken and post recognized credentials awarded. Participants who are 16, 17 and 18 years of age must have written parental permission or qualify for another exemption from compulsory attendance law to participate in the program.

By signing this I agree to share my directory information, which consists of name, address, telephone number, date of birth, dates of attendance, degrees obtained, and field of study.

By signing this I agree to share my personal identifiable information regarding my enrollment in the program and in post-secondary institutions.

By signing this I agree to share my personal identifiable information regarding my employment status or history to all local, state, federal, partners and/or stakeholders.

I acknowledge that by signing below I fully understand the requirements and conditions for receiving Adult Education and Literacy Services.

Table

	Student Signaturefield type signature	Datefield type date	Parent/Guardian Signaturefield type signature
row 1	Student Signaturefield type signature	Datefield type date Date will be captured on form submission	Parent/Guardian Signaturefield type signature Only needed if student is under the age of 18

Please give three (3) contacts and their phone numbers. We may need to contact you about attendance and or graduation

	Namefield type single line	Relationship to youfield type single line	Phonefield type single line
1	Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Relationship to youfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Phonefield type single line Input blocked. Maximum character limit of 4000 characters reached.
2	Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Relationship to youfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Phonefield type single line Input blocked. Maximum character limit of 4000 characters reached.
3	Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Relationship to youfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Phonefield type single line Input blocked. Maximum character limit of 4000 characters reached.

I have completed the Orientation Session and I fully understand all of the information presented and in this Handbook. I agree to comply and abide with all of the rules and regulations.
First Namefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Last Namefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Phone Numberfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Are you an English as a Second Language (ESL) Student?field type radio button
Are you an English as a Second Language (ESL) Student?YesNo
Students' English translator speaker contact namefield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Translator telephone numberfield type single line
Input blocked. Maximum character limit of 4000 characters reached.
Signaturefield type signature Datefield type date
row 1 Signaturefield type signature
Datefield type date
Date will be captured on form submission
Add

	Signaturefield type signature	Datefield type date
row 1	Signaturefield type signature	Datefield type date Date will be captured on form submission

Educational & Career Goals

Educational, career, and/or job goals I plan to accomplish this year.field type multi line
Be as specific as possible.
How do you plan on accomplishing these goalsfield type multi line
Be as specific as possible.

Family & Community Goals

Family, community, and/or life goals, I plan to accomplish this year.field type multi line
Be as specific as possible.
How do you plan to accomplishing these goals?field type multi line
Be as specific as possible.

Learning Style Survey
Please complete this survey to better understand your learning style. Enter one of the numbers for each question.
- 1 = Never Applies
- 2 = Sometimes
- 3= Often

	field type drop-down
I get lost or I'm late if someone tells me how to get to a new place and I didn't write down the directions	field type drop-down
When trying to remember someone's telephone number, it helps me if I get a picture of it in my head.	field type drop-down
If I am taking a test, I can see the textbook page and where the answer is	field type drop-down
I listen better when I took at the person talking.	field type drop-down
It's hard for me to understand a joke when someone tells me	field type drop-down
It's better for me to get work done in a quiet place.	field type drop-down
I enjoy doodling and my notes contain lots of pictures.	field type drop-down
I remember something better if I write it down.	field type drop-down

Totalfield type single line
Input blocked. Maximum character limit of 4000 characters reached.

	field type drop-down
My written work dosen't look neat to me. My papers have crossed-out words and erasures.	field type drop-down
It helps to use my finger as a pointer when reading.	field type drop-down
Papers with very small print or poor copies bother me.	field type drop-down
I understand how to do something if someone tells me rather thatn having to read the directions.	field type drop-down
I remember things I hear, rather that things I see.	field type drop-down
Writting is tiring. I press down too hard with my pen.	field type drop-down
It's hard for me to read other people's hardwriting.	field type drop-down
If I had the choice to lean new information via lecture or textbook, I would choose lecture.	field type drop-down

Totalfield type single line
Input blocked. Maximum character limit of 4000 characters reached.

	field type drop-down
I don't like to read directions; I'd rather start doing.	field type drop-down
I learn best when I'm shown how to do something, and I have the opportunity to do it.	field type drop-down
Studying at a desk is not me.	field type drop-down
I tend to solve problems through a trial and error approach. rather than step by step method.	field type drop-down
Before I follow directions, it helps me to see someone else do it first.	field type drop-down
I am not skilled in giving verbal explanations.	field type drop-down
I think well when I have the freedom to move around.	field type drop-down
When I can't think of specific word, I'll use my hands a lot and call something a "what-cha-call-it"	field type drop-down

Totalfield type single line
Input blocked. Maximum character limit of 4000 characters reached.

Best Plus
Date*field type date Scale Score*field type single line
row 1 Date*field type date
Scale Score*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Add

	Date*field type date	Scale Score*field type single line
row 1	Date*field type date	Scale Score*field type single line Input blocked. Maximum character limit of 4000 characters reached.

Best Literacy

	Date*field type date	Form*field type drop-down	Scale Score*field type single line
row 1	Date*field type date	Form*field type drop-down	Scale Score*field type single line Input blocked. Maximum character limit of 4000 characters reached.

CASAS

	Date*field type date	Form*field type single line	Level*field type drop-down	Scale Score*field type single line
CASAS LAW LISTENING	Date*field type date	Form*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Level*field type drop-down	Scale Score*field type single line Input blocked. Maximum character limit of 4000 characters reached.
LAW READING	Date*field type date	Form*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Level*field type drop-down	Scale Score*field type single line Input blocked. Maximum character limit of 4000 characters reached.
MATH GOALS	Date*field type date	Form*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Level*field type drop-down	Scale Score*field type single line Input blocked. Maximum character limit of 4000 characters reached.
READING GOALS	Date*field type date	Form*field type single line Input blocked. Maximum character limit of 4000 characters reached.	Level*field type drop-down	Scale Score*field type single line Input blocked. Maximum character limit of 4000 characters reached.

TABE

	Date*field type date	Form*field type drop-down	Level*field type drop-down	Scale Score*field type single line
READING	Date*field type date	Form*field type drop-down	Level*field type drop-down	Scale Score*field type single line Input blocked. Maximum character limit of 4000 characters reached.
MATH	Date*field type date	Form*field type drop-down	Level*field type drop-down	Scale Score*field type single line Input blocked. Maximum character limit of 4000 characters reached.
LANGUAGE	Date*field type date	Form*field type drop-down	Level*field type drop-down	Scale Score*field type single line Input blocked. Maximum character limit of 4000 characters reached.

Form title

Basic Information

Employment Information

Educational History

Goals

Release of Information and Permission to Participate in the Program

Table

Please give three (3) contacts and their phone numbers. We may need to contact you about attendance and or graduation

Educational & Career Goals

Family & Community Goals

Best Plus

Best Literacy

CASAS

TABE