Fillable Adult Basic Education Student Enrollment Data (Rowan College of South Jersey)

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Adult Basic Education Student Enrollment Data (Rowan College of South Jersey)

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Cumberland Campus • 3322 College Drive, Vineland, NJ 08360 • 856-691-8600 • RCSJ.edu
©RCSJ/Publications/C&M0620
Cumberland Campus
Adult Basic Education Student Enrollment Data
Date enrolled: / / Cohort:
CWED: M,T,W,R 9 am – 12 noon M,T,W,R 1pm – 4pm
Alms Center: M,T,W,R 10 am – 1 pm Vineland Library: ABE M,T,W,R 4:30 pm – 7 pm
Salvation Army: ESL M,T,W,R 10 am – 1 pm Vineland Library: ESL M,T,W,R 10 am – 1 pm
Forest Lakes: ABE M,T,W,R 10 am – 1 pm
Last Name _________________________ First Name _________________________ Middle Initial _____
Social Security # ____________________ Phone # ____________________ Alt. # ___________________
Address ________________________________ City _________________ State _______ Zip ____________
Date of Birth: ____/____/____ Age ______ Email address: _______________________________
Ge
nder M F Emergency Contact: ___________________________________________________
Please answer both the Ethnicity and the Race questions below
Ethnicity: choose only one Race: choose one or more
No, Hispanic/Latino American Indian or Alaskan Native Native Hawaiian or Pacific Islander
Yes, Hispanic/Latino Black or African American Asian White
Status on Entry:
Employed — full time Immigrant U.S. Veteran
Employed — part time U.S. Citizen Low Income
Unemployed —
(actively seeking employment) F1 Visa Homeless
Single Parent or Guardian Dislocated Worker Displaced Homemaker
Not looking for work Disabled Public Assistance
Unavailable for work Learning Disability Retired
Schooling: U.S. Based Non-U.S. Based
Did not attend school
Attended Grades 1–5
Attended Grades 6–8
Attended Grades 9–12
Did you ever attend any Adult Education Program before? Yes No If yes, where? __________________
Did you ever take the HSE test? Yes No If yes, where? ____________________________________
Are you looking for the following after you receive your diploma? enter college career training get a job
How did you hear about our program? __________________________________________________________
Forms: (staff use only) Assessment: (staff use only)
Check Proper ID Appraisal: ____________________________________
Certificate of Non-Enrollment (Ages 16-21) Pre-TABE: _____________ Post-TABE: ___________
Parental Consent (Under Age 18) Entered into LACES ____/____/____ Initials: ______
Cumberland Campus • 3322 College Drive, Vineland, NJ 08360 • 856-691-8600 • RCSJ.edu
©RCSJ/Publications/C&M0620
Cumberland Campus
ABE Prep Class Expectations
The primary purpose of the Adult Basic Education prep class is to prepare you to take the
High School Equivalency (HSE) exam in order to earn your New Jersey High School Diploma.
This takes your time, dedication, and hard work to be successful in this program.
While in the classroom you should always:
Honor the rights of others in the classroom. Disruptive behavior will not be tolerated.
Verbal or physical confrontations, foul language and inappropriate conversations will
be grounds for immediate dismissal from the program.
You must sign-in each class session and sign-out each class session; this includes
your name, time of arrival and time of departure. This is your responsibility, not
the responsibility of the teacher or other classmates. You must not be more than
15 minutes late to class, the instructor can refuse entry into the classroom.
All cell phones and electronics must be silenced and put away before entering the
classroom. No use of cell phones or electronics during class. No food or drinks
are allowed in the classroom!
Be aware of smoking areas during breaks. All smoking is in designated smoking areas
only. Be aware of all emergency exits at each class location.
You must commit to attend 4 days/evenings a week, 3 hours each class for a
minimum of 12 hours a week. You must attend all class hours. Only 3 excused
absences are allowed. The first class session consists of completing paperwork and
taking the Locator. Dates for the Pre-TABE and Post-TABE will be shown on your
calendar. It’s important that you attend all these pre-selected skill assessment dates.
Prior to taking the High School Equivalency exam or to be able to participate
in our graduation, we strongly suggest that a student must:
1. Have completed class hours
2. Taken the Pre-TABE and Post-TABE skill assessments
and show a grade level improvement
3. Email all scores from the HSE exam back to the Coordinator
or college representative
I have read the above rules and regulations of the ABE Prep program and will abide by these rules.
I understand that while I attend this educational program, these rules will apply to me at all times.
I agree to be accountable for all my hours and assessments according to the above requirements.
Signature: ___________________________________________ Date: __________________
2019-2020 ccc class expectations
Cumberland Campus • 3322 College Drive, Vineland, NJ 08360 • 856-691-8600 • RCSJ.edu
©RCSJ/Publications/C&M0620
Cumberland Campus
Release of Information Form
I, (
print name) __________________________________________________ authorize Rowan College
of South Jersey ~ Cumberland Campus to release my educational records, which include my name, social
security number, date of birth, address, scores, and attendance to the New Jersey Department of Labor and
Workforce Development, 1 John Fitch Way, Trenton NJ and the (consortium lead agency) Salem County
Vocational and Technical School, at 890 Route 45, Woodstown, NJ 08098, which is our partner with the
Department of Labor and Workforce Development for the administration of our educational programs.
I also authorize the release of my educational records, which include my name, social security number,
date of birth, address, scores, attendance and student ID number, to any other facility/program that
I may be affiliated and/or associated with.
Please check all that apply:
Millville Housing Authority Vineland Housing Authority Bridgeton Housing Authority
Family Success Center:
Gateway Holly City Forest Lakes Monarch
Food Stamps/SNAP
TANF
Welfare
Medicaid
Parole Officer’s Name: _____________________________________________________________
Parole Officer’s Phone Number: _________________________________________________
I understand that the use of my records is limited to and in connection with the audit and/or evaluation
of federally supported education programs, or in connection with the enforcement of the federal legal
requirements related to the WIOA Title II grant program.
My signature is an acknowledgement that I have read and voluntarily consent to the release of the
above-mentioned information.
St
udent Signature ________________________________________________ Date _______________
(Parent/Guardian if under 17) __________________________________________________________
Social Security Number _______________________________________________________________
*SSN is used for matching purposes only.
2019-2020 release of information form
Cumberland Campus • 3322 College Drive, Vineland, NJ 08360 • 856-691-8600 • RCSJ.edu
©RCSJ/Publications/C&M0620
NJ Department of Education
HSE Testing Unit
PO Box 500
Trenton, NJ 08625
I (We) hereby authorize the NJ Department of Education and the applicable HSE/GED user jurisdiction (collectively the
“HSE/GED Testing Program”) to provide copies of the documents, information, and/or records identified below to the
following third party: Site/Name: Rowan College of South Jersey — Cumberland Campus
Address: 3322 College Drive
City/State: Vineland, NJ Zip Code: 08360
The specific information, documents and/or records that I am authorizing the NJ Department of Education; HSE/GED
Testing Program to release are: (Please indicate the particular test and specific test date(s) for which materials are being
requested.)
HSE/GED Testing records for individual identified below:
___________________________________________________________________________________________
In requesting and authorizing disclosure of these documents, information, and/or records, I hereby agree to the following:
1.
I understand and acknowledge the HSE/GED Testing Program’s right to make an independent determination,
at its sole discretion of whether the information and records identified above are subject to disclosure under
the HSE/GED Testing Program’s policies for disclosing information to third parties.
2.
I hereby release the NJ Department of Education, the HSE/GED Testing Program, its employees, its attorneys, its
governing bodies, and its agents from any and all liability and claims of every kind and character that are base
d
upon or
relate in any way to the disclosure of information in accordance with this authorization of any actions
of the third party identified above.
3.
I agree that this authorization is valid until such time as the NJ Department of Education; HSE/GED Testing
Program has received written notice from me (or from me and my parent or guardian, if I am a minor)
withdrawing permission to disclose the documents or information specified above to the third party identifie
d
a
bove. In the event that permission is withdrawn, the NJ Department of Education; HSE/GED Testing Program
shall nevertheless remain fully protected from any and all claims and liability relating in any way to information
released by the NJ Department of Education; HSE/GED Testing Program prior to its receipt of the written
withdrawal notice and to any actions of the third party.
4.
I understand that, subject to its independent determination, the NJ Department of Education; HSE/GED Testing
P
rogram will disclose the designated material that it has at the time it receives my request. I also understand that
in the absence of an additional request from me, the HSE/GED Testing Program will not provide information that
becomes available at a later date.
I
have read this authorization carefully and hereby acknowledge that I fully understand it. I further affirm that
I am giving this authorization knowingly of my own free will.
Please print your name: _______________________________________________________________
Signature of Candidate: ______________________________________________________________________
If you have previously taken the GED/HSE test under a different name, please indicate that name below:
__________________________________________________________________
Candidate’s SSN/SIN: ___________________ Date of Birth: ____/____/____ Date: _______________
Signature of Candidate’s Parent or Guardian (if candidate is under 18 years of age)
________________________________________________________________ Date: _______________
*FORML6* Revised 07/10
L-6 Authorization for Disclosure
Of HSE/GED Documents and Information
Cumberland Campus • 3322 College Drive, Vineland, NJ 08360 • 856-691-8600 • RCSJ.edu
Certification of Non-enrollment
in School for 16 to 21 Year Olds
Agency: __________________________________________________________________________
This form must be completed and presented at the time of registration in an adult education program.
If any information is misrepresented on this form, the State of New Jersey reserves the right
to invalidate any program and deny further access to any adult program options.
PART A: To be completed by applicant
(for 16 and 17 years olds Only — Parent/Guardian must sign)
__________________________ ______________________ _____________________
First Name: Last Name: Social Security Number:
__________________________ ______________________ _____________________
Number and Street: County: ZIP Code:
Telephone: ____________________________________________________ Birth Date: ____/____/____
Name of last New Jersey high school attended:
Address of last New Jersey high school attended:
Applicant’s Signature: __________________________________________ Date: ________________
Parent/Guardian’s Signature: _____________________________________ Date: ________________
(For 16 and 17-year olds)
PART B: To be completed by the Superintendent or High School Principal in the Public-School
District of Residence.
I, the undersigned, do hereby certify that is not on school rolls in this district.
Signature of Principal or Superintendent: _______________________________ Date: ___________
Title: Telephone:
Place Raised School
Seal or Notary’s
Signature Here
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Cumberland Campus • 3322 College Drive, Vineland, NJ 08360 • 856-691-8600 • RCSJ.edu
NEW JERSEY DEPARTMENT OF EDUCATION
Division of Teacher and Leader Effectiveness
Office of Certification/Induction/ High School Equivalency Testing, PO Box 500
Trenton, New Jersey 08625-0500
Phone: 609-777-1050
Fax: 609-984-0573
Chris Christie Kimberley Harrington
Governor Acting Commissioner
Instructions: This form must be completed by any 16 and/or 17 year old individual who is currently not enrolled in a public/private
high school and interested in taking the Adult Education Assessment. This form must be signed by a parent/guardian and presented to the
Chief Examiner when registering for the Assessment. Please be advised that this signed consent form will be provided to your
current school district, if you want to take the High School Equivalency Assessment this is mandatory. For any questions, contact
the New Jersey Department at (609)777-1050 or
adulted_info@doe.state.nj.us or visit www.state.nj.us/education/adulted.
PART A
: ►TO BE COMPLETED BY APPLICANT
_____________________ _______ ____________________________ _______________
First Name Middle Initial Last Name Social Security Number
_____________________________________________ ____________________ ___________________ ________________
Address City State Zip Code
Telephone: _________________________________ Date of Birth: __________________________ Age: _______________
Month Day Year
I certify the following: I am at least 16 years of age. I am not currently enrolled in school. I have not graduated from an accredited
high school in the United States or Canada. I have not previously earned a State-issued high school diploma or earned scores sufficient
to qualify for a high school equivalency certificate/diploma in any state (unless an exception is applicable). I certify that I am
eligible to take the High School Equivalency Assessment and that the information provided is accurate. I understand that if the
information is misrepresented, the Chief Examiner can refuse to administer the Tests. In addition, the New Jersey State
Department of Education reserves the right to invalidate the Assessment scores if information is misrepresented.
Applicant’s Signature: ________________________________________________________________ Date:
_______________
Part B: ►TO BE COMPLETED BY PARENT OR GUARDIAN
I certify the following: The individual named above has my legal consent to waive his/her right to attend a local school. I have officially withdrawn this
individual from the school of residence, day school or educational program and he or she cannot return to the public school system. I further consent
to his/her participation in taking the High School Equivalency Tests. I understand that the New Jersey State Department of Education reserves the
right to invalidate these Test scores if information submitted on this form is misrepresented. The signature below confirms the previous statements.
Parent/Legal Guardian’s Signature: __________________________________________________________ Date: _________________________
Print Name: ______________________________________________________________________________ Phone: ________________________
Address: ________________________________________________________________________________________________________________
City: __________________________________________________________ State: __________________________ Zip Code: ______________
Name of last school district: _______________________________________ Last school address: ______________________________________
Date of withdrawal from school: ____________________ School Tel #: _______________________ School Fax #: _______________________
School Email Address: ____________________________________________________________________________________________________
CERTIFICATE OF CONSENT TO PARTICIPATE FORM
High School Equivalency Testing
Cumberland Campus • 3322 College Drive, Vineland, NJ 08360 • 856-691-8600 • RCSJ.edu
Cumberland Campus
Adult Education Program Notification Sign-up
I __________________________ would like to sign up for text message and email alerts from
the RCSJ Adult Education Program. You may opt out of this service at any time by notifying
staff at 856-200-4531.
Name: _______________________________________________________________________________________________________________________________________________________________________
Mobile Phone: ________________________ Email Address: _______________________________
Signature: ________________________________________________ Date: __________________
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Adult Basic Education Student Enrollment Data (Rowan College of South Jersey)

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Completed 21 October 2021

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