Logo for: Manchester Adult Education

Adult Education Student Information Form

Please fill out this form to register for High School Completion, ESL, and/or Citizenship classes. (* denotes required fields)

Student Type*
Last Name*
 First Name*
Middle Name
 Suffix
SASID (for office use only)
 Residence Area*
Country Born*
 Birthdate*
Gender*
 Pronouns
Social Security #
 Ethnicity (must select at least one)*
Race (must check at least one)*
 Highest Education Level Completed on Entry*
Write in grade level:*
Write in grade level:*
Last High School Attended*
 Highest Education Level Location*
Employment Status*
 Which of the following do you have at home so we can contact you and/or connect you to services? (check all that apply)*
Miscellaneous Characteristics (check all that apply)
 How did you hear about Adult Education*
Home Street Address*
 Zip Code*
City*
 County*
State*
 Home Phone
Mobile Phone*
 Work Phone
Email Address*
 Name of Employer
Employer Address
 Employer Phone
Parent/Guardian of (check all that apply and list number)
If yes, how many?*
If yes, how many?*
If yes, how many?*
WIOA Core Programs (check all that apply)
Start Date*
Start Date*
Start Date*
Start Date*
Start Date*

Emergency Contact Information

Name of Emergency Contact*
 Emergency Telephone*

All Students Must Check One Category Below

Low-level Literacy
ABE, GED, NEDP, CDP students
(All students who do not have an SSD at entry)*
 English Language Learner/Cultural Barriers
ESL/ELL students*

Check All That Apply Below

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 a 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 or Runaway Youth
Are you homeless? Do you lack a regular and adequate residence? 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 and 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 or 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?*

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

Applicant Signature *
 Date *