AEL-Enrollment-Form All AE students must have an enrollment form on file before services are rendered. Please fill out the form below. Fill out information completely and correctly to the best of your knowledge. Have you attended another Adult Education site? Yes No WhereWhenName First Name Middle Initial Last Name SOCIAL SECURITY NUMBERTEXAS DL/ID – OTHER DOCUMENT NUMBER LAN TX DL/ID Other DATE OF BIRTH* MM slash DD slash YYYY AGE OF STUDENT* 16 17-18 19+ GENDER Male Female ETHNICITY* Hispanic / Latino Not Hispanic / Latino Person of Cuban, Mexican, Puerto, Rican, South or Central American, or other Spanish culture or origin, regardless of raceRACE - MUST CHECK AT LEAST ONE RACE American Indian or Alaskan Native Indicates that he/she is a member of an Indian tribe, band, nation, or other organized group or community. Including any Alaska Native Village.Person having origins in any of the original peoples of Far East, SE Asia, Indian Subcontinent. Asian Person having origins in any of the original peoples of Far East, SE Asia, Indian Subcontinent.American person having origins in any of the black racial groups of Africa. Black/African American American person having origins in any of the black racial groups of Africa.Person having origins in any of the original peoples of Hawaii,Guam, Samoa, or other Pacific Islands. Native Hawaiian or Pacific Island Person having origins in any of the original peoples of Hawaii,Guam, Samoa, or other Pacific Islands.In any of the original peoples of Europe, Middle East or North Africa. White In any of the original peoples of Europe, Middle East or North Africa.Identifying InformationSTUDENT STREET ADDRESSCITYSTATEZIPCODEMOBILE PHONEHOME NUMBERWORK NUMBEREMAIL ADDRESS* PrivacyI 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 (THECB) master enrollment records for the sole purpose of statistical analysis and adult education program improvement. Information will be released and exchanged between Texas Education Agency (TEA) and THECB. Participants who are 16, 17 and 18 years of age must have parent or guardian permission to participate in the program.Do Not Release Directory Information Yes Share Data with Texas Higher Education Coordinating Board* Yes No Share Data with Texas Education Agency* Yes No Parent/Guardian Authorize Consent Share Data withTexas Higher Education Coordinating Board Yes No Texas Education Agency Yes No DisabilityDisability* Yes No Participant didn't disclose Physical/Chronic Health Condition Mental or Psychiatric Hearing - Related Cognitive/ Intellectual Physical/Mobility Impairment Vision - Related Learning Disability Participant Did Not Disclose Type of Disability Veteran CharactersticsVeteran Characteristics Yes No Eligible Veteran Status Yes <= 180 days Yes, Eligible Veteran Yes, Other Eligible Person No Disabled Veteran Yes No Yes, Special Disabled Date of Military Separation MM slash DD slash YYYY Employment and Education InformationEmployed Yes No Employed, but received Notice of Termination Yes No or Military Separation Yes No Not in Labor Force Yes No Not Employed Yes No Unemployed 27+ Consecutive Weeks Yes No Hours Employed Per WeekReason for Not Looking for Work Full-time caregiver/ Parent Disabled Incarcerated Ineligible to work Dependent Institutionalized Other Type of Community Rural Urban School Status at Program Entry In Post- School, Secondary Not Attending School, Graduate or has a Recognized Equivalent Not Attending School or Secondary Dropout Not Attending School Within Age Compulsory School Attendance Highest School Grade Completed First Grade Completed Second Grade Completed Third Grade Completed Fourth Grade Completed Fifth Grade Completed Sixth Grade Completed Seventh Grade Completed Eight Grade Completed Ninth Grade Completed Tenth Grade Completed Eleventh Grade Completed Twelfth Grade Completed No school grades completed Highest Education Level Completed Attained secondary school diploma Attained a secondary school equivalency The participant with a disability receives a certificate of attendance/ completion as a result of successful completing an Individualized Education Program (IEP) Completed one or more years of post secondary education Attained a post secondary technical or vocational certificate (non-degree) Attained an Associate’s degree Attained a Bachelor’s degree Attained a degree beyond a Bachelor’s degree No Educational Level Completed Location of Highest Education Completed In the US Outside of the US Migrant and Seasonal Farmworker Status Seasonal Farmworker Migrant and Seasonal Farmworker Dependent of a seasonal, or migrant and seasonal farmworker No Public Assistance InformationOn Public Assistance Yes No Participant did not disclose Expanded Eligibility for TANF Yes No Participant did not disclose Exhausting TANF within two years Yes No Not applicable Additional CharacteristicsFoster Care Youth Yes No Homeless Status Yes No Low-Income Status Yes No English Language Learner Yes No Cultural Barriers Yes No Immigrant Yes No Participant did not disclose Displaced Homemaker Yes No Single Parent Yes No Dislocated Worker Yes No Parent of Child(ren) ages 0-5 Yes No Participant did not disclose Parent of Child(ren) ages 6-10 Yes No Participant did not disclose Parent of Child(ren) ages 11-13 Yes No Participant did not disclose Parent of Child(ren) ages 14-18 Yes No Participant did not disclose Ex-Offender Status at Program Entry Yes No Participant did not disclose Date Released from Incarceration MM slash DD slash YYYY One-Stop Program Participant Yes No Unknown In Correctional Facility Yes No In Community Corrections Yes No Other Institutionalized setting Yes No On Parole Yes No On Probation (Community Supervision) Yes No Family Literacy Participant Yes No In Workplace Literacy Program(s) Yes No Participant in Job & Training Program Yes No One Stop Center Referral Yes No Participant did not disclose TANF Referral Yes No Participant did not disclose Referral from College Yes No Participant Goals (Optional)Primary Obtain High School Diploma Obtain HSE Obtain a Job Retain job or advance in job Enrollment in College or Other Training Secondary Leave Public Assistance Greater Involvement in Children’s Education Greater Involvement in Community Activities Improve Basic Skills Obtain U.S. Citizenship Obtain/Improve: Parenting Obtain/Improve: Occupational Skills Obtain/Improve: Community Resource Achieve Citizenship Skills Greater Involvement in Children’s Literacy Activities Register to Vote or Vote for First Time Make Progress in English (LEP) General Involvement (Volunteering) Obtain/Improve: Health Care Obtain/Improve: Government and Law Obtain/Improve: Consumer Economics Other OtherEMPLOYMENT PARTICIPANT RELEASE OF INFORMATIONI hereby give my consent to the Texas Workforce Commission to release personal identifiable information regarding my employment status or history to the THECB and/or TEA for the sole purpose of statistical analysis, administration or evaluation for the improvement of state adult education programsStudent CHECK THIS BOX AUTHORIZING CONSENT CHECK THIS BOX NOT AUTHORIZING CONSENT PARENT/GUARDIAN CHECK THIS BOX AUTHORIZING CONSENT CHECK THIS BOX NOT AUTHORIZING CONSENT PARTICIPANT RELEASE OF INFORMATION AND PERMISSION TO PARTICIPATE IN THE PROGRAMThe 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 and/or failure to disclose information is grounds for rejection on my application, withdrawal of acceptance, cancellation of enrollment, and/or could affect my legal status in this country. Participants who are 16 years of age must have a court order. By signing this form, parents of 17 and 18 year old students give 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. Yes No STUDENT NAME (PRINT)STUDENT SIGNATUREDate MM slash DD slash YYYY PARENT NAME (PRINT)PARENT/GUARDIAN SIGNATUREDate MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
