Fillable Important info for completing the enrollment PDF (Temple College)

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Important info for completing the enrollment PDF (Temple College)

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The Important info for completing the enrollment PDF (Temple College) form is 8 pages long and contains:

  • 4 signatures
  • 148 check-boxes
  • 83 other fields

Country of origin: US
File type: PDF

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Important info for completing the enrollment PDF
Student Enrollment Form
• You will need a valid form of identification. This can be a passport, birth certificate,
Social Security card, Driver’s License, State ID. If you leave that area blank, we will
reach out to you and follow up on what you can bring.
• Make sure you give us a CURRENT address, phone number and email address.
• Make sure you enter this information CORRECTLY.
• Read and Click on any of the boxes that apply to you.
• You will need a parent signature if you are 16-18 years old.
• You may be able to sign the pdf form depending on what program you have on your
device. However, if you can not sign it, please wait until you have completed the entire
PDF file. There will be instructions at the end of this paper to help you sign the pdf.
Remind Program Consent Form
• This page is needed for the consent of calling, emailing or messaging you through the
Remind application.
• Make sure your name, phone number, and email address are CORRECT
Class Preference
• Fill in preferred box, you can check both boxes if both apply to you.
ITEC Plan
• Fill in your career goals, long and short term.
• Fill in your educational goals, long and short term.
• Leave page 6 blank. This is a review of your goals that will occur at a later date.
*** Follow these steps to sign the papers in this file. All signatures NEED to be completed***
1. Only do this if you could not sign the forms through the pdf file itself.
2. Do this AFTER you have completed the entire PDF file and SAVED it to your
documents. Save it as Enrollment- (your name).
3. Go to https://www.digisigner.com/free-electronic-signature/
4. Click on the blue square that says “SIGN PDF NOW”
5. Locate your PDF file on your documents.
6. Once the file loads, located the signature spots on the PDF file and left click it.
You can then type your name and pick 1 of 6 signatures or click draw and you
will be allowed to sign with your mouse.
7. Do NOT change the ink color!
8. Move and edit the signature so that it is on the signature line.
9. Once you are done with the signatures on this page, go to the top and click Done.
10. Click Download Document and Save it as Enrollment- (First and Last Name) and
send the completed file to us at aelenrollment@templejc.edu
Texas Adult Education and Literacy Student Enrollment Form
Temple College 2020-2021
LAST NAME
FIRST NAME
MIDDLE INITIAL
RETURNING
STUDENT
SOCIAL SECURITY NUMBER
OR
TX Driver License or TX ID #
GENDER
Yes
Male Female
Participant did not self-identify
* STAFF ONLY - SSN # VERIFIED BY/ DATE
If no Social Security Number or TX DL is provided, please indicate why
Do not wish to disclose
Never been issued an SSN, but is eligible to receive one
Do not have a Texas driver license or identification number
Do not remember SSN
Is not eligible for a SSN
* STAFF ONLY - TX DL or ID VERIFIED BY/ DATE
ETHNICITY >> Must Select ONE
RACE » Must Check at Least ONE Race
Hispanic/Latino
Not Hispanic
Person of Cuban, Mexican,
Puerto Rican, South or Centr
al
American, or other Spanish
culture or origin, regardless of
race
American Indian
or
Alaskan Native
Indicates that he/she is a member
of an Indian tribe, ban
d, nation, or
other organized group or
community. Including any Alaska
Native Village.
Asian
Person having
origins in any of
the original
peoples of Far East,
SE Asia, Indian
Black/African
American
American person having
origins in any of the black
racial
groups of Africa.
Native
Hawaiian or
Pacific Island
Person having origins
in any of the original
peoples of Hawaii,
Guam, Samoa, or
other Pacific Islands.
White
Person having
origins in any of
the original
peoples of
Eur
ope, Middle
East or North
Africa.
IDENTIFYING INFORMATION
STUDENT STREET ADDRESS
CITY, STATE, ZIP CODE
CELL PHONE
HOME PHONE
EMAIL ADDRESS
DATE OF BIRTH
AGE
Emergency Contact
/ /
Contact Name and Phone Number
M M D D Y Y Y Y
Employment Information
Reason for not looking for work
Employed: Yes No
Hours Employed per week
Unemployed 27+ consecutive weeks Yes
Employed but received notice of termination Yes
Not employed, but looking for work Yes
Full-time caregiver/parent
Disabled
Ineligible to work
Dependent
Incarcerated
Institutionalized
Other
____________________________________
PARTICIPANT GOALS
Primary
Obtain HS Diploma Obtain HS Equivalency Enrolled in College/Other
Obtain a Job Retain Job/Advance in Job
Secondary
Leave Public Assistance Obtain/Improve: Occupational Skills
General Involvement
Involvement in Child's Education Obtain/Improve: Community Resources Obtain/Improve: HealthCare
Involvement in Community Activities Register to Vote/First time Vote Obtain/Improve: G
ovt and Law
Improve Basic Skills Involvement in Child Literacy Other
Obtain US Citizenship Make progress in English _________________________
Obtain/Improve: Parenting Obtain/Improve: Consumer Economics
Revised: 07/01/2020 - lr
Disability
Education Information
Additional Characteristics
Yes No Choose not to
disclose
If, yes please choose at least one below:
Physical/Chronic Health Condition
Physical/Mobility Impairment
Mental Learning Disability
Vision Cognitive/Intellectual
Hearing Choose not to disclose
Highest Grade Completed
_________________________
Complete Inside U.S. Completed Outside U.S.
Check all that apply:
Homeless/Runaway
Low Income
Foster Care Youth
Cultural Barriers
Immigrant
Displaced Homemaker
Single parent
Dislocated Worker
Parent of ages 0-5
Parent of ages 6-10
Parent of ages 11-13
Parent of ages 14-18
Job Corps
Correctional Facility
Community Corrections
Other Institutionalized
On Parole
On Probation
Ex-Offender
Family Lit. Participant
Workplace Lit. Participant
Participant in Job Training
Veteran Status
Attained High School Diploma
Attained GED or Equivalent
Some College/Vocational _____# of Yrs.
Associates Degree
Bachelor’s Degree
Degree Beyond Bachelor’s
No Educational Level Completed
Degree:
_________________________________________________
Yes No
Eligible Veteran Status
Yes <= 180 days No
Yes, Eligible Veteran
Yes, Other Eligible Person
Disabled Veteran
Yes
No
Yes, special disabled
Date of Actual Military Separation
Migrant and Seasonal Farmworker Status
MM
DD
YYYY
Seasonal Farmworker Adult
Migrant Farmworker Adult
Migrant Seasonal Farmworker Youth
Dependent of Farmworker Adult
Dependent of Farmworker Youth
Not Applicable
Language
On Public Assistance
Is English your first language?
Yes No
Yes No Choose not to disclose
Type of Community
Expanded Eligibility for TANF
Referral
Rural
Urban
Yes No Choose not to disclose
One-Stop Center Referral
TANF Referral
College Referral
WIOA Adult
WIOA Dislocated Worker
WIOA Youth
One-Stop Program Participation
Adult Education
Youthbuild Grant Number
Vocational Rehabilitation
Job Corps
Wagner-Peyser Employment Service
#______________________
Yes
Vocational Rehabilitation & Employment
Both Vocational Rehabilitation and VR&E
No
Unknown
Yes
Reportable Individual
No
Unknown
Yes No
Unknown
Yes, Local Formula
Yes, Statewide
Yes, Both Local Formula and Statewide
Reportable Individual
None of the above/ Does not apply
PARTICIPANT RELEASE OF INFORMATION AND PERMISSION TO PARTICIPATE IN THE PROGRAM
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 on my application, withdrawal of acceptance, and
cancellation of enrollment. Participants who are 16 years of age must have a court order. By signing this form, parents of 17 and 18 year old students
give permission to participate in the program. I give my consent for release of directory information, which consists of name, address, telephone
number, date of birth, dates of attendance, degrees obtained and field of study.
POST SECONDARY ENROLLMENT PARTICIPANT RELEASE OF INFORMATION
I hereby give my consent to release personal identifiable information regarding my enrollment in post-secondary institutions as matched to
the Texas Higher Education Coordinating Board (THECB) master enrollment records for the sole purpose of statistical analysis and adult
education program improvement.
Information will be released and exchanged between Texas Education Agency (TEA) and THECB. Participants who are 16, 17 and 18 years of age
must have parent or guardian permission to participate in the program.
EMPLOYMENT PARTICIPANT RELEASE OF INFORMATION
I hereby give my consent to the Texas Workforce Commission to release personal identifiable information regarding my employment status or
history to the THECB and/or TEA for the sole purpose of statistical analysis, administration or evaluation for the improvement of state adult
education programs.
PHOTO AND VIDEO RELEASE
I hereby give my consent to have my picture or my video released by Temple College and the Adult Education Program for the sole purpose of
advertising the adult education programs offered by said institution. Participants who are 16, 17, and 18 year of age must have written permission to
participate in the program.
I hereby give my consent to the Texas Workforce Commission to release personal identifiable information regarding my employment status or
history to the THECB and/or TEA for the sole purpose of statistical analysis, administration or evaluation for the improvement of state adult
education programs.
By signing below I AUTHORIZE CONSENT to the above mentioned statements.
_______________________________________ _____________ ________________________________________ _____________
STUDENT SIGNATURE DATE PARENT/GUARDIAN SIGNATURE DATE
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signature
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signature
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2020.07.01 - lr
Program Consent
2020 - 2021
Fees and payment; Responsibility for usage charges
By using the Remind Services, you may receive e-mail or text messages on your phone
or mobile device, which may cause you to incur usage charges or other fees or costs in
accordance with your wireless or data service plan. Any and all such charges, fees, or
costs are your sole responsibility. You should consult with your wireless carrier to
determine what rates, charges, fees, or costs may apply to your use of the Services.
_____________________________________________________________
Student’s Printed Name
____________________________________________________________
Student’s Signature
____________________________________________________________
Cell Phone Number
____________________________________________________________
Email Address
______________________________
Date
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signature
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Class Preference Checklist
HSE Classes
Which time of day works best for your schedule?
Morning class
9:00 am – 11:00 am
Evening class
6:30 pm – 8:30 pm
Which type of student do you think you want to be?
Classes online, possibly some face to face classes (Hybrid Learning)
Strictly online, after my 12 hours of class time (Distant Learning only)
__________________________________________
___________________________
Printed Name Date
___________________________________________
Phone Number
Revised: 07/01/2020 - lr
Adult Education and Literacy Program
Individual Training, Education and Career Plan (ITEC)
HSE
My Future Plan
Career Goals I hope to achieve this goal by (month/year)
Career Goal:
Short Term
(within the next year)
/
Career Goal:
Long Term
(within the next 2-5 years)
/
What education and training are required for my chosen career field?
___ High School Diploma/Equivalency
___ Bachelor’s Degree
Vocational/Technical Training
Master’s Degree
Associates Degree
___ Doctorate Degree
I do not have a career goal yet, but I would like to explore the following career fields:
Education Goals I hope to achieve this goal by (month/year):
Education Goal:
Short-term
(within the next year)
/
Education Goal:
Long-term
(within the next 2-5 years)
/
What do I want to achieve in this adult education program?
How have I made time in my schedule to attend class and study? Do not forget to include home life
management, child care, and transportation.
What things will make it difficult to achieve my educational goals?
What do I need from my teacher to help me achieve my education goals?
Printed Name ___________________________________________________________
Assessment Results (enter information if available)
(Examples: Career Assessments, Personality Tests, Learning Style Inventories, CASAS progress test, GED
practice test, GED tests, etc.)
Assessment Date
Assessment Name/Type
Score/Results
Goal Review (review progress of goal)
Did you accomplish your goal(s)? ______________________________________________________________
Do you need to extend your goal date? _________________________________________________________
Are your original goals still valid? ______________________________________________________________
Do you need to make any changes to your original goal? ___________________________________________
Do you feel you are making progress towards your goal? ___________________________________________
What can you do to progress in your work towards your goal? ______________________________________
What can we do to help you achieve your goal(s)? ________________________________________________
Student Signature _______________________________________ Date ________________________
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Completed 4 February 2021

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