Learner Registration Form

Learner Registration Form Directions: Please complete all fields below. Fields with asterisks (*) indicate data that is required in InTERS.

*Application Date: ______/______/______Month Day Year *Site Program: ______

*SSN: ______

*First Name: ______*Last: ______MI: ____

*Address: ______

*City: ______*State: ______*Zip: ______

*Phone Number: ______Emergency Phone Number: ______

*Date of Birth: _____/_____/_____ *Gender: ____Male ____Female Month Day Year

*Annual Household Income ______

*Household Size ______

Office Use Only:

Classroom ______Online ______

Term (Ex. 2014-2015): ______

1 Learner Name: ______

*Ethnicity (Choose only one): *Check all that Apply: Hispanic (A person of Cuban, Mexican, Impairments (physical, mental, or Puerto Rican, South or Central American, or learning) other Spanish culture or origin, regardless of Lives in urban area (city) race) Lives in rural area (outside city) Other Receives Public Assistance *Race (Choose one or more): Low Income American Indian Displaced Homemaker Asian Single Parent African American Dislocated Worker Pacific Islander Is a Dependent or Has Dependents White

*U.S. Citizen: Yes No *Native Country: ______(Leave blank if USA) *Employment Status: *Current Enrollment Type: Employed Adult Basic Education Seeking Employment Adult Secondary Education Not in the Labor Force Community Corrections Correctional Facilities *Educational Status: English as a Second Language Current 9-12 Family Literacy Did not graduate Homeless Program GED Other Institutional Program Graduated Work-Based Project Received a Certificate Workplace Literacy Spec. Ed. Diploma

2 Release of Information Form

I, (print name) ______, am enrolled in an adult basic education (ABE) program. This ABE program works with the following programs and agencies to help students improve their skills and earn better jobs:  Other state-funded adult education programs  WorkOne offices and job training programs  Public and private colleges  State executive offices, departments, and agencies including the Indiana Department of Workforce Development (DWD), Division of Adult Education and the Indiana Department of Education

By signing this form, I understand and agree to the following:  DWD use of directory information (name, address, birth, and social security number) to match test score records, wage information, and college/training program enrollment records that assist the state to evaluate and improve its programs and to report results to the federal and state government  The sharing of information between the agencies and programs listed above. This information may include my name, enrollment information, education/career goals, test scores, and employment history. The information will be kept strictly confidential and will be used for program administration, research, and evaluation purposes.

______Signature of Student / Parent or Guardian* Date

______Signature of Staff / Witness to the Student’s Signature Date

*Students under the age of 18 must have this consent form signed by the student’s parent or guardian.