Adult Education Enrollment form

Step 1 of 13

Personal Identifying Information

Student Type*

HSE

ESL

CCR/NCBO

IET

Enrollment Date*

Month

Day

Year

Name*

First Middle Initial Last

DL/ID*

Driver's License (DL)

State Identification card (ID)

DL/ID State*

DL/ID Number*

Date of Birth*

Month

Day

Year

Age*

in years

Gender*

Male

Female

Non-Binary

Participant did not self-identify

No answer

Ethnicity*

Yes - Hispanic/Latino

No - Not Hispanic/Latino

Participant did not self-identify

Race*

Check all that apply.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Contact Information

Address*

Street Address Address Line 2 City State ZIP Code

Mobile Phone

Work Phone

Home Phone

Email*

Equal Opportunity Information

Disabled*

Yes

Participant did not self-identify

Category of Disability

Check all that apply.

The impairment is primarily physical, due to a chronic health condition.

The impairment is primarily physical, including mobility.

Because of mental illness, psychiatric disability, or emotional condition, the participant has serious difficulty concentrating, remembering, or making decisions.

The participant is blind or has serious difficulty seeing.

The participant is deaf of has serious difficulty hearing.

The participant has a learning disability.

The participant has a cognitive or intellectual disability.

Participant does not wish to disclose his/her category of disability.

Veteran Characteristics

Veteran Status*

Yes

Status not known

Eligible Veteran Status*

Yes, less than or equal to 180 days

Yes, eligible Veteran

Yes, other eligible person

Disabled Veteran*

Yes

Yes, special disabled

Veteran Spouse*

Yes

Date of Actual Military Separation*

Year

Month

Day

Employment and Education Information

Employment Status at Program Entry*

Employed (enter hours employed per week in box below)

Employed, but received Notice of Termination of Employment or Military Separation is pending

Not in labor force (choose reason for not looking for work in box below)

Unemployed

Long-Term Unemployed at Program Entry*

Yes, unemployed > 27 consecutive weeks

Hours Employed per Week*

Reason for not looking for work*

(Not in labor force)

Full-time caregiver/parent

Disabled

Incarcerated

Ineligible to work

Dependent

Institutionalized

Other

Type of Community*

Rural

Urban

School Status at Program Entry*

In-school, secondary school or less

In-school, alternative school

In-school, post-secondary school (college or training program)

Not attending school or secondary school dropout (19 or older)

Not attending school; secondary school graduate or has a recognized equivalent

Not attending school; within age of compulsory school attendance (Under 19)

Highest School Grade Completed*

1-12 or 0 for no grades completed

Please enter a number from 0 to 12.

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 successfully completing an Individualized Education Program (IEP)

Completed one or more years of post-secondary education

Attained a post-secondary technical or vocational certificate (non-degreed credential)

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 Level Completed*

In the US

Outside the US

Post-Secondary Follow-up Questions

for Outside the US only

What is your field of study?*

Agriculture, Food & Natural Resources

Architecture & Construction

Arts, A/V Technology & Communication

Business, Management & Administration

Education and Training

Finance

Government & Public Administration

Health Science

Hospitality and Tourism

Human Services

Information Technology

Law, Public Safety, Corrections & Security

Manufacturing

Marketing, Sales & Service

Science, Technology, Engineering & Mathematics

Transportation, Distribution & Logistics

Other

From what Country was the degree or credential obtained?*

From what Institution was the degree or credential obtained?*

How may years of work experience do you have in this field?*

Do you want to be reemployed in the same field?*

Yes

Migrant and Seasonal Farmworker Characteristics

Migrant and Seasonal Farmworker Status*

Seasonal Farmworker Adult

Migrant Farmworker Adult

MSFW Youth

Dependent Youth

Dependent Adult

Public Assistance Information

On Public Assistance*

Yes

Did not disclose

Expanded Eligibility for TANF*

Yes

Not Applicable

Exhausting TANF within 2 years*

Yes

Not Applicable

Additional Youth Characteristics

Foster Care Youth*

Yes

Additional Reportable Characteristics

Status at Program Entry

Homeless Status*

Yes

Low-Income Status*

Yes

English Language Learner*

Yes

Cultural Barriers*

Yes

Participant did not self-identify

Immigrant*

Yes

Did not disclose

Displaced Homemaker*

Yes

Single Parent*

Yes

Participant did not self-identify

Parent of Child(ren) ages 0-5*

Yes

Did not disclose

Parent of Child(ren) ages 6-10*

Yes

Did not disclose

Parent of Child(ren) ages 11-13*

Yes

Did not disclose

Parent of Child(ren) ages 14-18*

Yes

Did not disclose

Ex-Offender Status*

Yes

Did not disclose

Date released from Incarceration

(YYYYMMDD)

One-Stop Program Participation

Participant received services under Title 1, Chapter 4, Subtitle C of WIOA

WIOA Adult*

Yes, Local Formula

Yes, Statewide

Yes, Both Local Formula and Statewide

Reportable Individual

WIOA Youth*

Yes, Local Formula

Yes, Statewide

Yes, Both Local Formula and Statewide

Reportable Individual

WIOA Dislocated Worker*

Yes, Local Formula

Yes, Statewide

Yes, Both Local Formula and Statewide

Reportable Individual

Adult Education: Yes

WIOA Job Corps*

Yes

Reportable Individual

Unknown

WIOA Vocational Rehabilitation (VR)*

Yes (youth transition services for secondary students with disabilities)

Vocational Rehabilitation & Employment (adult services)

Both VR and VR&E (if participant received services from both VR and VR&E)

Unknown

WIOA Wagner-Peyser Employment Service*

Yes

Reportable Individual

Unknown

WIOA YouthBuild Grant Number

For Corrections and Institutional Program Participants

In Correctional Facility*

Yes

In Community Corrections*

Yes

Other institutionalized setting*

Yes

On Parole*

Yes

On Probation*

Community Supervision

Yes

Special Program Type

Family Literacy Participant*

Yes

In Workplace Literacy Program(s)*

Yes

Participant in Job & Training Program*

Yes

Referral Type

One-Stop Center referral*

Yes

Did not disclose

TANF referral*

Yes

Did not disclose

Referral from College*

Yes

Participant Acknowledgement 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, credential obtainment, and transition to postsecondary enrollment or employment. My signature below also authorizes use of my personally identifiable information, including my employment and wage information pre, during and post- enrollment for audit, study and evaluation of the Adult Education and Literacy program performance and other state and federally- funded programs. Such programs may include but are not limited to those under the laws administered by the Texas Education Agency and the Texas Higher Education Coordinating Board. I acknowledge that the Adult Education and Literacy program and that TWC may release personal identifiable information to other local, state, federal, partners and/or stakeholders for verification of state and federal program requirements, performance reporting, audit, evaluation, study and to monitor the programs performance. Participants who are 17 and 18 years of age must have written parental permission or qualify for another exemption from compulsory attendance law. Additional information may be found at: TWC Website Privacy & Security Information - https://www.twc.texas.gov/agency/laws-rules-policy/website-privacy-security-information

Participant Signature*

Date*

Month

Day

Year

Parent/Guardian Signature

For students 18 and under only

Date

Month

Day

Year

Texas Educating Adults Management System (TEAMS) Enrollment Intake Form

Personal Identifying Information

Contact Information

Equal Opportunity Information

Veteran Characteristics

Employment and Education Information

Post-Secondary Follow-up Questions

Migrant and Seasonal Farmworker Characteristics

Public Assistance Information

Additional Youth Characteristics

Additional Reportable Characteristics

One-Stop Program Participation

Adult Education: Yes

For Corrections and Institutional Program Participants

Special Program Type

Referral Type

Participant Acknowledgement and Release of Information