Tx Adult Education Enrollment Form

ADULT EDUCATION AND LITERACY STUDENT ENROLLMENT FORM

- Revised 7/17/14

STUDENT NAME

DOCUMENT TYPE (ONE ONLY)

DOCUMENT NUMBER

DATE OF BIRTH

GENDER

TITLE

LAST NAME (FAMILY NAME)

FIRST NAME

MI

Social Security # (Preferred)

MM

DD

YYYY

 Female





Mr.

Mrs.

Locally Assigned Number

 Male





Ms.

Dr.

 OTHER

STREET ADDRESS

CITY

STATE

ZIP CODE

MOBILE TEL.#

WORK TEL.#

Ext #

HOME TEL. #

E-MAIL ADDRESS

ETHNICITY

RACE (CHECK ALL THAT APPLY)

STUDENT HISTORY

Are you Hispanic or Non-Hispanic?

 Hispanic/Latino

 Not Hispanic

 American Indian or Alaska Native  Asian  Black/African  Native Hawaiian/Pac Islander  White

HAVE YOU ATTENDED ANOTHER ADULT ED. PROGRAM?

 YES  NO If Yes, Where:_________________________

PARTICIPANT STATUS UPON ENTRY INTO THE PROGRAM

 Disabled

Employment Status (Check one only):

Other Status:

Highest Grade Completed ______

Profile Variables:

 On Public Assistance

 Employed # Hours Week __________

 Low-Income

 Displaced Homemaker

 Completed IN the U.S.

 On Parole

 Unemployed - looking for work

 Single Head of Household  Dislocated Worker

 Completed OUTSIDE U.S.

 On Probation (Community

 Living in Rural Area

(places

 Learning-Disabled Adult

 Unemployed - NOT looking for work

Supervision)

of less than 2,500 inhabitants

 Never Attended School

*For Corrections and Institutional Funded

 Participant in Job & Training Program

and is not near any metropolitan

 High School graduate

Program Participants Only

Reason for not looking for work (required)

 TANF Referral

area with a population greater

 *In Correctional Facility

 In Community Corrections

 GED graduate?

(Choose one):

 Expanded Eligibility for TANF &

than 50,000, or in a city with

 *Other Institutionalized Setting

 Some college, no degree?

 Full time caregiver/parent

adjacent areas of high density)

Parent of Dependent Child

 Disabled

 Incarcerated

**In Specifically Designed Program Only:

 College or professional degree

 One-Stop Center Referral

 Ineligible to work  Dependent

 **Family Literacy

 Living in Urban Area

 Unknown

 Institutionalized

 **In Workplace Literacy Program(s)

 Other _______________________

 **In Program for the Homeless

PARTICIPANT ACKNOWLEGEMENT AND RELEASE OF INFORMATION

The information provided is complete and correct to the best of my knowledge. I agree to abide by Adult Education Program policies, rules and regulations. I further understand the submission of false information is grounds for

rejection of my application, withdrawal of acceptance, and cancellation of enrollment. My signature below shall constitute acknowledgement to statistical use of my records of enrollment, progress, and transition under the

application laws, TEA regulations and Adult Education Program internal policies as aggregate statistical data in the evaluation of the program, and shall constitute a precondition for enrollment in this adult education and literacy

program. I acknowledge that the Adult Education Program and the Texas Education Agency (TEA) will release information to other state and federal agencies for verification, follow-up, and tracking and to generate reports to

monitor the program. Participants who are 16 years of age must have a court order and 17 year of age must have parent or guardian written permission to participate in the program.

I give my consent for release of directory information, which consists of name, address, telephone number, date of birth, dates of attendance, degrees obtained, and field of study.

□ Check this box to AUTHORIZE CONSENT

□ Check this box as parent or guardian AUTHORIZING CONSENT

□ Check this box NOT AUTHORIZING CONSENT

□ Check this box as parent or guardian NOT AUTHORIZING CONSENT

I hereby give my consent to release personal identifiable information regarding my enrollment in post-secondary institutions as matched to the Texas Higher Education Coordinating Board master enrollment records for the sole

purpose of statistical analysis and adult education program improvement. Information will be released and exchanged between the Texas Education Agency and the Texas Higher Education Coordinating Board.

□ Check this box to AUTHORIZE CONSENT

□ Check this box as parent or guardian AUTHORIZING CONSENT

□ Check this box NOT AUTHORIZING CONSENT

□ Check this box as parent or guardian NOT AUTHORIZING CONSENT

I hereby give my consent to the Texas Workforce Commission to release personal identifiable information regarding my employment status or history to the Texas Higher Edu cation Coordinating Board and/or the Texas Education

Agency, for the sole purpose of statistical analysis, administration or evaluation for the improvement of state adult education programs.

□ Check this box to AUTHORIZE CONSENT

□ Check this box as parent or guardian AUTHORIZING CONSENT

□ Check this box NOT AUTHORIZING CONSENT

□ Check this box as parent or guardian NOT AUTHORIZING CONSENT

*Parents/Guardians by signing the Acknowledgement and Release of Information section you are giving your child permission to be part of our Adult Ed. GED program.

_________________________________________________

______________________

___________________________________________________

______________________

STUDENT SIGNATURE

DATE

PARENT/GUARDIAN SIGNATURE

DATE

BASELINE ASSESSMENTS

(Office Use Only)

TABE BASELINE ASSESSMENT

DATE

FORM USED

LEVEL

SUBJECT

SCALE SCORE

NRS LEVEL

DOS



9



10



E



M



D



A

READING

O



9



10



E



M



D



A

MATH

O

9

10

E

M

D

A

LANGUAGE

O













BEST BASELINE ASSESSMENT

DATE

DOMAIN

SCORE

NRS LEVEL

DOS

DATE

DOMAIN

SCORE

NRS LEVEL

DOS

BEST PLUS ORAL

O

BEST LITERACY:



B



C



D

O

TEST ADMINISTERED BY:

SUPERVISOR:

DATE ENTERED INTO TEAMS:

ENTERED INTO TEAMS BY:

SITE:

CLASS NUMBER:

INSTRUCTOR:

START DATE: