Blue River Adult Ed Registration Step 1 of 4 - Background 0% STUDENT INFORMATIONACADEMIC YEAR 2020-2021Class Location*Blue River Career ProgramsSoutheast Community Services CenterEdinburgh Community SchoolsJob Corps - AtterburyShelby Co. JailWhich class will you be attending?*HSE - Morning (Mon & Wed 9-1PM)HSE - Evening (Mon & Wed 5-9PM)ESL - Afternoon (Tues & Thurs 12:30-3:30PM)ESL - Evening (Tues & Thurs 5-8PM)Job Corps - TASC PrepShelby County Jail HSECNA - (varies)QMA - (varies)CDA - (varies)NCCER Core & OSHA 10 - (varies)CHW - (varies)HVAC - (varies)Customer Service - (varies)IT Fundamentals - (varies)CompTIA Security+ - (varies)WorkIN - (varies)Are you an Excel student?*YesNoWe are sorry, as an Excel Center student you can not enroll in Adult Education classes at the same time.Are you a former student (of adult education)?*YesNoAre you under 18 years old?*YesNoPlease download, complete and return the Exit Interview Form. Download FormName* First Middle Last Student InformationAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have a home phone?*YesNoHome Phone Number (EX. 123-456-7890)*Do you have a mobile phone?*YesNoMobile Phone Number (EX. 123-456-7890)*Do you prefer to be contacted via text message?*YesNoDo you have an email address?*YesNoEmail Address:*Make this an email you check often. Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleEthnicity/Race*African AmericanAmerican IndianAsianHispanicPacific IslanderWhiteUS Citizen*YesNoNative Country (example: USA)* Employment InformationEmployment Status: (Choose the one that BEST describes you.)*EmployedUnemployedNot working, not looking for a job, not in the labor forceEmployed, termination/separation pendingUnemployed more than 26 weeksEmployer Name:*Date hired:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Educational InformationCheck your highest level of education:*No formal schoolGrades 1-5Grades 6-8Grades 9-12 (no diploma)Certificate of Completion (Disability/IEP)High Shcool Diploma / Alternative credentialHSE (High School Equivalency) / GEDSome postsecondary (no degree)Certificate / License (no degree)Associate's DegreeBachelor's DegreeBeyond Bachelor's DegreeUnknownLast grade completed:*Enter your highest grade level you completed. If you attended a postsecondary training program or college, enter "12+".Previous School Location:*U.S.-based schoolsnon-U.S.-based schoolsSchool Attend Status at Entry:*Not attending school: (16-17 years old)Not attending school: Exited High School before graduationNot attending school: Secondary school graduate or recognized equivalentCurrent Enrollment Type:*Adult EducationEnglish as a Second LanguageEMERGENCY CONTACT INFORMATIONEmergency Contact's Name* First Last Emergency Contact's Phone (EX. 123-456-7890)*Relationship to you:*Spouse/Significant OtherParentLegal GuardianOther family memberFriend Required for State FundingPART A: DEMOGRAPHICSDo you have an impairment or disability?*YesNoType of impairment or disability:* Select All Physical Mental Learning Have you ever had an Individualized Education Program (IEP)?*YesNoNot SureSelect the type of area in which you live:*Urban (Housing, businesses, and shopping are close to you)Rural (Fields, forests, and no businesses or shopping are near you.)Do you receive public assistance? **This includes government assistance such as SNAP (food stamps), TANF (Temporary Assistance for Needy Families), etc.*YesNoLow Income (This means that you believe you do not earn enough money to pay bills, etc.)*YesNoAre you a displaced homemaker? (This means that you had to go back to work because your spouse left home.)*YesNoAre you a single parent? (This means that you are the custodial single parent.)*YesNoAre you a dislocated worker? (This means that you lost your job through a layoff or closing.)*YesNoRequired for State FundingPART B: DEPENDENT OR HAS DEPENDENT(S)You claim children on your tax forms, or you are claimed on someone else's tax forms as a dependent.*YesNoAnnual family income (yearly income before taxes):*Household size (number of people living with you, including yourself):*Do you have a HIP (Healthy Indiana Plan) card?*YesNoI don't knowRequired for State FundingPART C: DEMOGRAPHICSFoster Care Youth (Are you currently in the foster care system, or have you been in the foster care system?)*YesNoHomeless / Runaway (Are you homeless and/or do you currently have no place to live?)*YesNoNon-English spoken at home (Is a language OTHER THAN ENGLISH the primary language in your home?)*YesNoMigrant Worker (Are you a seasonal farm worker?)*YesNoActive Military (Are you or your spouse on active duty status?)*YesNoRequired for State FundingPART D: DEMOGRAPHICSVocational Rehabilitation (Have you received services for disabilities?)*YesNoWagner Peyser Services (Are you receiving WorkOne Employment Services?)*YesNoEx-Offender (Have you have been arrested or convicted?)*YesNoCultural Barriers (Do you believe that your attitudes, religion, customs, skin color, or dress have affected your job opportunities?)*YesNo How did you hear about our program? (Check all that apply.)* brochure/flyer court referral Department of Workforce Development website employer friend/relative newspaper public assistance referral shelter TV/Radio WorkOne referral Robocall Email Social Media (Facebook, Instagram, Twitter, etc) Other Student Rights & ResponsibilitiesYou have chosen to attend a class with Blue River Career Programs Adult Education. In efforts to help you reach your goals, we must all make a commitment to work hard and to never give up. Below you will find your “Rights.” The student’s “Rights” are our promises and commitments to you as our student. You will also find the student’s “Responsibilities,” your “Responsibilities.” These are the promises and commitments which we need from you. Without both sets of promises, neither you or us will be successful during our time together. Please read carefully and consider what each item means. It is your Right… · to receive Quality Instruction in the class you have chosen to attend by qualified teachers who truly care. · to be provided useful and relevant Study Materials that help you with your class goals. · to have a Safe and Respectful learning environment while in our classrooms. · to have your Questions Answered to the best of our abilities or be referred to other resources that can. It is your Responsibility… · to be Dependable by being on time, being present at class every day, and following through with what you say you are going to do. · to be Engaged by practicing active listening, asking questions, and doing your homework. · to Follow the Building’s Rules by being respectful of others and their belongings whether you are in the classrooms, halls, bathrooms, parking lots, etc. If you are in agreement with these promises, please sign below along with your instructor. By both parties signing, it serves as proof of the commitments described above during our time working together towards your goals. Student Signature*Please type your full name.Date Date Format: MM slash DD slash YYYY Release FormI am participating in an adult education (AE) program. This AE program works with the following programs and agencies to help students improve their skills and earn better jobs. ·Other state-funded adult education programs ·Work One offices, job training programs, or service agencies ·Public and private colleges ·State executive offices, departments, and agencies including the Indiana Department of Workforce Development (DWD), Division of Adult Education and the Indiana Department of Education ·The Court System (Probation officers, Case Managers, etc.) By signing this form, I understand and agree to the following: ·DWD use of directory information (name, address, birth and social security number) to match test score records, wage information, and college/training program enrollment records that assist the state to evaluate and improve its programs and to report results to the federal and state government ·The sharing of information between the agencies and programs listed above. This information may include my name, enrollment information, education/career goals, test scores, and employment history. The information will be kept strictly confidential and will be used for program administration, research, and evaluation purposes. MEDICAL INFORMATION (Select ONE)*I have no medical conditions or I am not taking any medications which could affect my ability to perform in the classroom.I have medical conditions and may be taking medications as listed below that could affect my ability to perform in the classroom. (For example, I use and inhaler, or I am diabetic.)I have read and agree to the terms of the following: ·Internet and Other On-Line Access Contract ·Student Agreement ·Persistence Policy ·Academic Progression Policy ·Proof and Standing PolicyBy typing your name you consent that this is your electronic signature and consent to the above information* YES Signature of Student*Signature of Parent or Guardian**Students under the age of 18 must have the consent form signed by the student’s parent or guardian. Last 4 Digits of Social Security Number *