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?YesNoWhereWhenName First Name Middle Initial Last Name SOCIAL SECURITY NUMBERTEXAS DL/ID – OTHER DOCUMENT NUMBER LAN TX DL/ID Other DATE OF BIRTH* Date Format: MM slash DD slash YYYY AGE OF STUDENT* 16 17-18 19+ GENDERMaleFemaleETHNICITY*Hispanic / LatinoNot Hispanic / LatinoPerson 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. Asian Person having origins in any of the original peoples of Far East, SE Asia, Indian Subcontinent. Black/African American American person having origins in any of the black racial groups of Africa. Native Hawaiian or Pacific Island Person having origins in any of the original peoples of Hawaii,Guam, Samoa, or other Pacific Islands. 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*YesNoShare Data with Texas Education Agency*YesNoParent/Guardian Authorize Consent Share Data withTexas Higher Education Coordinating BoardYesNoTexas Education AgencyYesNoDisabilityDisability*YesNoParticipant 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 CharacteristicsYesNoEligible Veteran StatusYes <= 180 daysYes, Eligible VeteranYes, Other Eligible PersonNoDisabled VeteranYesNoYes, Special DisabledDate of Military Separation Date Format: MM slash DD slash YYYY Employment and Education InformationEmployedYesNoEmployed, but received Notice of TerminationYesNoor Military SeparationYesNoNot in Labor ForceYesNoNot EmployedYesNoUnemployed 27+ Consecutive WeeksYesNoHours Employed Per WeekReason for Not Looking for Work Full-time caregiver/ Parent Disabled Incarcerated Ineligible to work Dependent Institutionalized Other Type of CommunityRuralUrbanSchool Status at Program EntryIn Post- School, SecondaryNot Attending School, Graduate or has a Recognized EquivalentNot Attending School or Secondary DropoutNot Attending School Within Age Compulsory School AttendanceHighest School Grade CompletedFirst Grade CompletedSecond Grade CompletedThird Grade CompletedFourth Grade CompletedFifth Grade CompletedSixth Grade CompletedSeventh Grade CompletedEight Grade CompletedNinth Grade CompletedTenth Grade CompletedEleventh Grade CompletedTwelfth Grade CompletedNo school grades completedHighest Education Level CompletedAttained secondary school diplomaAttained a secondary school equivalencyThe 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 educationAttained a post secondary technical or vocational certificate (non-degree)Attained an Associate’s degreeAttained a Bachelor’s degreeAttained a degree beyond a Bachelor’s degreeNo Educational Level CompletedLocation of Highest Education CompletedIn the USOutside of the USMigrant and Seasonal Farmworker Status Seasonal Farmworker Migrant and Seasonal Farmworker Dependent of a seasonal, or migrant and seasonal farmworker No Public Assistance InformationOn Public AssistanceYesNoParticipant did not discloseExpanded Eligibility for TANFYesNoParticipant did not discloseExhausting TANF within two yearsYesNoNot applicableAdditional CharacteristicsFoster Care YouthYesNoHomeless StatusYesNoLow-Income StatusYesNoEnglish Language LearnerYesNoCultural BarriersYesNoImmigrantYesNoParticipant did not discloseDisplaced HomemakerYesNoSingle ParentYesNoDislocated WorkerYesNoParent of Child(ren) ages 0-5YesNoParticipant did not discloseParent of Child(ren) ages 6-10YesNoParticipant did not discloseParent of Child(ren) ages 11-13YesNoParticipant did not discloseParent of Child(ren) ages 14-18YesNoParticipant did not discloseEx-Offender Status at Program EntryYesNoParticipant did not discloseDate Released from Incarceration Date Format: MM slash DD slash YYYY One-Stop Program ParticipantYesNoUnknownIn Correctional FacilityYesNoIn Community CorrectionsYesNoOther Institutionalized settingYesNoOn ParoleYesNoOn Probation (Community Supervision)YesNoFamily Literacy ParticipantYesNoIn Workplace Literacy Program(s)YesNoParticipant in Job & Training ProgramYesNoOne Stop Center ReferralYesNoParticipant did not discloseTANF ReferralYesNoParticipant did not discloseReferral from CollegeYesNoParticipant 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 programsStudentCHECK THIS BOX AUTHORIZING CONSENTCHECK THIS BOX NOT AUTHORIZING CONSENTPARENT/GUARDIANCHECK THIS BOX AUTHORIZING CONSENTCHECK THIS BOX NOT AUTHORIZING CONSENTPARTICIPANT 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.YesNoSTUDENT NAME (PRINT)STUDENT SIGNATUREDate Date Format: MM slash DD slash YYYY PARENT NAME (PRINT)PARENT/GUARDIAN SIGNATUREDate Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
