Student Registration Form

Please complete AZ Adult Education Participant Application below

"*" indicates required fields

WIOA Title II Arizona Adult Education Participant Registration

Eligibility for Services

A.R.S. §15-232(B) states that “The Department of Education shall provide classes under this section only to adults who are citizens or legal residents of the United States or are otherwise lawfully present in the United States. This subsection shall be enforced without regard to race, religion, gender, ethnicity or national origin.”
If you are not sure about your eligibility, please consultprogram staff.

Please mark only one eligibility option.*

If you are not sure about your eligibility, please consult program staff.

I am a citizen of the United States of America.

I am a legal resident of the United States of America.

I am lawfully present in the United States of America for another reason.

None of the above

I affirm under penalty of perjury that I am a citizen of the United States, a legal resident of the United States, or otherwise lawfully present in the United States. Should my status change, I understand that it is my responsibility to withdraw from classes until such a time that I am again lawfully present in the United States.

Printed Name as it appears on Identification presented*

Participant Signature*

Date*

Registration

Today's Date*

Program Type*

Adult Basic Education

English Language Instruction

ARIZOINA@WORK Test Date

(Only applicable if workforce test date is prior to today’s date and will replace enrollment date from above)

NOTE: ARIZONA@WORK staff must have current TABE certification awarded by ADE/AES for tests to be considered valid for adult education purposes.)

Have you, or are you currently, enrolled in another adult education?

Yes

Name of Program:

PARTICIPANT NAME

Enter the participant’s LEGAL NAME as it appears on the presented identification.

First Name*

Middle Name

Last Name*

PREFERRED NAME/NICKNAME

DATE OF BIRTH*

GENDER/SEX (Required for Federal Reporting)*

Female

Male

MAILING ADDRESS

Participant’s full street address, including apartment number or “care of” (c/o) information. Please use abbreviations to make sure the information fits.

STREET ADDRESS, PO BOX, FPO, APO*

CITY*

STATE*

COUNTY*

ZIP CODE*

PHONE NUMBERS Primary Contact*

Emergency Contact

Email*

Do you have internet access?

Yes

Which devices do you own?

smartphone

tablet

laptop

other

PARTICIPANT SOCIAL SECURITY NUMBER

The US Department of Education requires that we report on the following demographic information:

ETHNICITY: Are you Hispanic/Latino?*

(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

Yes, Hispanic/Latino

NO, not Hispanic/Latino

RACE*

Please choose the best answer(s) from the choices below. If left unmarked, the program will choose for participant.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

NATIVE LANGUAGE*

English

Spanish

French

Cambodian

German

Somali

Chinese

Korean

Other

If other, please provide below:*

Do any of the following situations apply?

(Mark "Yes" or "No" for each question.)

Displaced Homemaker*

(The participant has been providing unpaid services to family members in the home and (a) has been dependent on the income of another family member but is no longer supported by that income; (b) is the dependent spouse of a member of the armed forces on active duty whose family income is significantly reduced because of (i) a deployment or a call or order to active duty pursuant to a provision of law, (ii) a permanent change of station, or (iii) the service-connected death or disability of the member; and (c) is unemployed or under-employed and is experiencing difficulty in obtaining or upgrading employment.)

Yes

Long-term Unemployed*

(The participant has been unemployed for 27 or more consecutive weeks)

Yes

Cultural Barrier*

(A perception of him-or herself as possessing attitudes, beliefs, customs, or practices that influence a way of thinking, acting, or working that may serve as a hindrance to employment)

Yes

Low Income*

(The participant (a) receives, or in the 6 months prior to application to the program has received, or is a member of a family that is receiving in the past 6 months assistance through the Supplemental Nutrition Assistance Program (SNAP), the TANF program, the Supplemental Security Income (SSI) program, or State or local income-based public assistance; (b) is in a family with total family income that does not exceed the higher of the poverty line or 70% of the lower living standard income level; (c) is a youth who receives, or is eligible to receive, a free or reduced-price lunch; (d) is a foster child on behalf of whom State or local government payments are made; (e) is a participant with a disability whose own income is the poverty line but who is a member of a family whose income does not meet this requirement; (f) is a homeless participant or homeless child or youth or runaway youth; or (g) is a youth living in a high-poverty area.)

Yes

Ex-Offender*

(The participant is a person who either (a) has been subject to any stage of the criminal justice process for committing a status offense or delinquent act, or (b) requires assistance in overcoming barriers to employment resulting from a record of arrest or conviction)

Yes

Migrant and Seasonal Farmworker*

(The participant is a low-income individual who for 12 consecutive months out of the 24 months prior to application for the program involved has been primarily employed in agriculture or fish farming labor that is characterized by chronic unemployment or underemployment and faces multiple barriers to economic self-sufficiency.)

Seasonal

Migrant & Seasonal

Homeless/Runaway Youth*

(The participant lacks a fixed, regular, and adequate nighttime residence; has a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings; is a migratory child who in the preceding 36 months was required to move from one school district to another due to changes in the parent’s or parent’s spouse’s seasonal employment in agriculture, dairy, or fishing work; or is under 18 years of age and absents himself or herself from home or place of legal residence without the permission of his or her family)

Yes

Individual with a Disability, including a learning disability*

(The participant indicates that he or she has any disability, defined as a physical or mental impairment that substantially limits one or more of the person’s life activities, as defined under the Americans with Disabilities Act of 1990)

Yes

Do any of the following situations apply?

(Mark "Yes" or "No" for each question.)

Youth in Foster Care/Aged Out of System*

(The participant is a person who is currently in foster care or has aged out of the foster care system)

Yes

Exhausting TANF within 2 years*

(The participant is within 2 years of exhausting lifetime eligibility under Part A of Title IV of the Social Security Act (42 U.S.C. 601 et seq.), regardless of whether he or she is receiving these benefits at program entry.)

Yes

Single Parent*

(The participant is a single, separated, divorced, or widowed individual who has primary responsibility for one or more dependent children under age 18, including single pregnant women.)

Yes

Refugee*

(A participant who has been forced to leave their country in order to escape war, persecution, or natural disaster.)

Yes

Living in Rural Area*

(any population, housing, or territory NOT in an urban area with less than 2,500 residents)

Yes

In Correctional Facility*

A participant that is located in a jail, prison, or other place of incarceration by government officials.) Applicable to programs receiving Sect. 225 funds only.

Yes

In Community Correctional Program*

(A participant that is either on probation or parole)

Yes

On Public Assistance?*

On Public Assistance

Not On Public Assistance

If On Public Assistance:

Food Stamps

WIC

Other

In Other Institutional Setting*

(A participant that is required by court order to reside in an institutional setting other than a jail or prison.) Applicable to programs receiving Sect. 225 funds only.

Yes

On Probation*

(Granted by the court as part of the convicted offender’s initial sentence. Probation may be granted in lieu of any jail time or after a short period of time in jail.)

Yes

Veteran of the Armed Forces*

(any person who served honorably on active duty in the armed forces (Army, Navy, Air Force, Marine Corps, and Coast Guard) of the United States.)

Yes

Identify Your Primary Reason for Seeking Adult Education Services

(Mark Yes/No for each question. ONE or BOTH must be marked as "Yes" in order for individual to be eligible for services.)

I want to learn English.*

(English Language Learner - The participant has a limited ability in speaking, reading, writing, or understanding the English language)

Yes

I want to improve in Math, English Language Arts, Science and/or Social Studies.*

(Basic Skills Deficient/Low Levels of Literacy - The participant has an inability to compute and solve problems, or read, write, or speak English at a level necessary to function on the job in the participant's family or in society)

Yes

EDUCATION AND EMPLOYMENT

Location of highest grade completed (Mark only ONE.)

U.S. School

Non – U.S. School

Mark the highest grade range completed:*

Mark current employment status:*

Employed

Employed but Received Notice of Termination of Employment or Military Separation is Pending

Not in the Labor Force

Unemployed

How did you learn about the Adult Education Program?

(Mark all that apply)

If you selected other please enter below

Annual Earnings*

(Mark only ONE)

By signing below, I represent that the information I have provided in this declaration and document is true and correct and that any document(s) I present are genuine. I understand that false or misleading information or documents related to this declaration may subject me to expulsion from the program as well as other legal actions.

Participant Signature*

Date

To attend adult education programs funded through the Arizona Department of Education (ADE), the participant must allow his or her information to be entered into and shared with designated adult education data systems, including the state-mandated testing platform, and all Workforce Innovation and Opportunity Act (WIOA) Core Partners’ data systems. This information will be shared with any ADE-funded adult education programs in which the participant enrolls, the participant’s instructors, and the Arizona Department of Education. This information is used for program operations, student instruction, employment opportunities, and to compile federal and state reports of non-identifying aggregate student data.

Participant Printed Name*

Participant Signature*

Date

Opt Out of Data Match

The adult education program is required to collect post-exit outcome data in the areas of employment, entry into post secondary education or training, and attainment of secondary diplomas. This is typically done through data matching with State agencies and educational institutions. The alternative to gathering this information through data match is contacting former students directly, such as by phone or email. If you wish to opt out of data match and instead be contacted after exiting the adult education program, check the I wish to Opt Out box:

I wish to Opt Out

Please complete AZ Adult Education Participant Application below

WIOA Title II Arizona Adult Education Participant Registration

Eligibility for Services

Registration

PARTICIPANT NAME

MAILING ADDRESS

Do any of the following situations apply?

Do any of the following situations apply?

Identify Your Primary Reason for Seeking Adult Education Services

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