Go Further With Lifelong Learning

Adult Education Registration

Please complete the following form: *

Returning Student

New Student

Select course you want to take: *

Personal Info:

Public Assistance: SAGA TANF/TFA Not Applicable
What is your native language? *	Country Born: *
If you were born outside the United States, how long have you lived in the United States?

Parent/Guardian of (check all that apply) *

Does not apply	Child(ren) 5 years & younger
Child(ren) 6 to 10 years	Child(ren) 11 to 18 years
Do you have your children in the Public School system? * Yes No
If yes, which school/s and grade/s?

Education:

How many years did you attend school? *

No high school diploma
High School diploma or alternate credential
GED®
Some college or university, no degree
College/University or Professional degree

Where was this highest educational level/degree attained? *

In USA

Not in USA

Last High School Attended (name and location if in the USA):

High School Name

Address

City

State

Zip

Last year attended (if attended in the USA)

Credits transferred to Adult Education

Barriers to Employment: (check all that apply) *

Miscellaneous Characteristics (check all that apply) *

Reasons for Enrollment (check all that apply)

The Shoreline Adult Education program serves the communities of Branford, North Branford, Guilford and Clinton. The state-mandated High School Diploma/GED®, English for Speakers of Other Languages (ESOL), and Citizenship classes are FREE to those that live in thesecommunities.

I understand that if I live outside of the communities listed above, I may still register if space is available, but I will be charged a non-refundable fee of $50 per semester or $75 per year. *

I understand that student information is confidential and will be used only for program administration, research and evaluation purposes. *

Typing my name on this registration form affirms that I understand student information is confidential and will only be used for program administration, research and evaluation purposes. *

Cultural Barriers	Disabled
Displaced Homemaker	English Language Learner
Ex-Offender	Foster Care Youth
Homeless	Long-term Unemployed
Low-Income	Low Levels of Literacy
Migrant or seasonal farmworker	Single parent
No TANF in 2 Years or Less	None

Comm. Alt. Corrections	Homeless
Institutionalized	Correctional Facility
Needs Transportation	Immigrant
Mother Under 17	Even Start Applicant
None

Community Earn Citizenship Use Community Services Vote	Employment Enter Employment Retain Employment Enter Military Not Applicable
Education * Improve Basic Skills (ABE/ESOL) Earn a HS diploma Enter College or Post-Secondary Training Enter Training Below Post-Secondary Level Progress Toward HS diploma (GED®, CDP, NEDP)	Required Instruction Court Order Required for Public Assistance
Family Increase Involvement in Children's Education Help more frequently with school Increase contact with children's teachers Move involved in children's school activities Increase Involvement in Children's Literacy Activity Read to Children Visit Library Purchase Books or Magazines
High School Diploma/GED®: For students registering for high school diploma /GED please upload a picture of a valid CT Driver's License, State ID, Passport or other photo identification card.

Adult High School Diploma/GED®	Citizenship Preparation (PM only)
ESOL (English for Speakers of Other Languages) AM PM