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Student Registration Form

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Please complete the following form: *

Select course you want to take: *

Personal Info:
Gender: *
Ethnicity: (must select one) *
Race: (check all that apply) *



Education:

Highest Education Level Completed on Entry: *Please write in the grade level
Where was this highest educational level/degree attained? *
Last High School Attended (name and location if in the USA):

Employment

Miscellaneous Characteristics (check all that apply)

Which of the following do you have at home so we can contact you and/or connect you to services? (check all that apply) *
If yes, please complete below:

WIOA Core Programs Co-Enrollment: (check all that apply) *

If yes, Start Date:

All students must check one category below:

Low literacy levels* ABE, GED, NEDP, CDP students (All students who do not have an SSD at entry) English Language Learner* ESL/ELL students

check all that apply:

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/Public Assistance* Do you have low income? Do you receive SNAP, TANF, SSI, or local public assistance? Are you a foster child or homeless?
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) 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/Runaway Youth* Are you homeless? Do you lack a regular and adequate resident? 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? (6-7 months or more?) Migrant or seasonal farmworker (if yes, select a subcategory)* Migrant or seasonal farmworker (if yes, select a subcategory)
Dislocated Worker* Have you been fired or laid off? Are you unemployed because the place where you worked has closed?


Single Parent/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?

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 these communities.

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. *