Technical College System of Georgia, Office of Adult Education, Student Registration Form, Effective June 19, 2020
*Name: __________________________________________________________________________________________
First Middle Last Suffix
STUDENT STATUS and SPECIAL POPULATIONS
*What is your work status? (select one)
Working
If working, are you? Full-time Part-time
Working, but my job is ending or my place of work is closing
Not working, but looking for work
Has it been 27 weeks (six months) or longer since you had a job? Yes No
Not working and not looking for work (stay at home, retired, incarcerated, etc.)
*Have you (or someone in your household) received any of the following in the last six months?
Yes No
TANF (Temporary Assistance for Needy Families)
Yes No
Have you received TANF for more than 2 years in total?
Yes No
SNAP (Supplemental Nutrition Assistance Program) “Food Stamps”
Yes No
SSI (Supplemental Security Income)
Yes No
State or Local income-based public assistance
How many family members, including yourself, have lived in your household in the last six months? _______
What is the total yearly income for all members of your household? $___________________
*Do any of the following statements apply to you?
Yes No
I have a low income.
Yes No
I am a former homemaker who is having trouble finding a job or a better job.
Yes No
I am a single parent. I am unmarried or separated from my spouse and have primary responsibility
for one or more dependent children under the age of 18 or I am a single, pregnant woman.
Yes No
I am homeless. I live in a motel, hotel, campground, transitional housing, or with another person
because I lost my house or apartment.
Yes No
I have a criminal record that makes it hard to find a job. (Do not select if you are currently incarcerated.)
Yes No
I am in the foster care system (or I used to be) and I am less than 24 years old.
Yes No
I am a farmworker.
(If yes, select a subcategory)
I am a seasonal farmworker who has worked the last 12 months in agricultural or fish farming labor.
I am a seasonal farmworker with no permanent residence (migrant).
I am a dependent of a farmworker.
*Are you an individual with a physical and/or learning disability? Yes No Do not wish to disclose
*Do you request special accommodation(s) based upon your physical and/or learning disability? Yes No
If the class you attend is associated with a correctional facility, please provide your GDC ID#: _______________
Language spoken at home: ____________________________ Country of Birth: ____________________________
Confidentiality Notice
This adult education program may release your student information for only specific reasons allowed under the Family Educational
Rights and Privacy Act (20 U.S.C. § 1232g; 34 CFR Part 99), such as program evaluation purposes. If you do not wish this information
to be disclosed, please check this box:
By signing this, I agree that the information submitted is accurate and can be used for contact and registration purposes.
*Student’s Signature: __________________________________________________ *Date: __________________
*Staff Member’s Signature: ______________________________________________ *Date: __________________
The Technical College System of Georgia and its grant-funded adult education providers do not discriminate on the basis of race, color, creed, national or ethnic origin, sex, religion,
disability, age, political affiliation or belief, genetic information, disabled veteran, veteran of the Vietnam Era, spouse of military member or citizenship status (except in those special
circumstances permitted or mandated by law).
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