Revised March 2020
Date form completed _________________
Name ________________________________________________________________________________________
Last First M.I. Maiden or other former name
Address _________________________________________________________ Apt.#________________ Phone 1 ____________________
City ___________________________
State _______ Zip___________ County __________
Phone 2 ____________________
Are you over 16 and formally withdrawn from school?
Yes No
Email __________________________________
General Information
Do you have an F-1 Visa?
Education (including from another country)
Last full grade completed ________________
Did you graduate from high school or its equivalent?
Yes No
What are your goals for coming to this program?
To improve basic skills
To improve English language skills (ESOL)
To obtain a job
To retain or improve current job
To earn high school equivalence or
secondary school diploma
To enter postsecondary education or training
To decrease public assistance received
To obtain citizenship skills
To register to vote or to vote for the first time
Other (Specify____________________)
staff use only
Release of Information Form
I, (print name) _________________________________________, authorize the Chancellor of the Ohio
Department of Higher Education to release my educational records, which includes my name, social
security number, student ID number, and date of birth, to the agencies listed below. The agency use of
these records is limited to and in connection with the audit and evaluation of Federally-supported
education programs, or in connection with the enforcement of the Federal legal requirements, that
relate to such programs.
Student/Examinee information released to:
Ohio Department of Job and Family Services Ohio Department of Education
30 East Broad Street, 32nd Floor 25 S. Front Street
Columbus, Ohio 43215 Columbus, Ohio 43215
Center for Human Resources Research
The Ohio State University
921 Chatham Lane
Suite 200
Columbus, OH 43221-2418
My signature is acknowledgement that I have read and voluntarily consented to the release of the
above-mentioned educational records as collected and utilized by the Aspire program I have previously
enrolled in or tested with.
______________________________ ________________________________________
Type name of Student/Parent or Guardian* Date
* Students under the age of 18 must have this consent form signed by the student’s parent or guardian.
** By signing this form, student (and/or guardian of student) acknowledges and affirms that, in addition to
the information sharing granted above, they are taking part in an online class which may be recorded and
electronically stored at any time for instructional and/or review purposes.
(Revised May 2020)
Modified for online orientation