Technical College System of Georgia, Office of Adult Education, Student Registration Form – Student Goals and Signatures Page – ESL Updated June 19, 2020
Adult Education Program
Student Registration Form – Student Goals and Signatures Page – ESL
Completion of this form is required for all adult learners in all programs. Required data is in bold with an asterisk (*).
Please print legibly. All signatures should be in ink.
*Pre-test date, form/level, score:
*Name: __________________________________________________________________________________________
First Middle Last Suffix
If you registered online, please complete this section:
• Are you an individual with a physical 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#: ________________
STUDENT GOALS – ESL
I want to improve my English skills in: My education goals are to: My career goals are to:
Listening
Reading
Writing
Earn a High School Equivalency
Enroll in a technical college
Enroll in a training program
Enroll in a 4-year college
Keep my job
Find a better job
*Do any of the following goals apply to you? (select all that apply)
I want to leave public assistance.
I want to achieve U.S. citizenship.
I want to achieve citizenship skills.
I want to increase my involvement in community activities.
I want to vote or register to vote.
I want to increase my involvement in my children’s education by:
Helping more frequently with their schoolwork.
Increasing contact with my children’s teachers to discuss children’s education.
Being more involved in my children’s school, such as attending school activities and parent meetings, and volunteering.
I want to increase my involvement in children’s literacy-related activities by:
Reading to children. Visiting a library. Purchasing books or magazines.
STUDENT RELEASE AND SIGNATURES
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 on this form and the Student Registration Form (online or paper-based) 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).
1. What goals do you want to
accomplish in the next year?
2. What goals do you want to
accomplish in the next 2-3 years?
Participants enrolled in Integrated English Literacy
and Civics Education (IELCE) must select at least
one of the following goals:
• Achieve citizenship skills
• Vote or register to vote
• Increase involvement in community activities
Participants enrolled in a Family Literacy program
must select at least one of the sub-goals for:
• Increase involvement in children’s education or
Increase involvement in children’s literacy activities
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