Fillable Registration Form (Coconino Community College)

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Registration Form (Coconino Community College)

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*denotes required eld (FY21 Rev 06/2020) GO TO NEXT PAGE
Arizona Adult Education
Participant Registration
Today’s Date* ____/_____/________
(Enrollment Date) MM DD YYYY
Program Type*: ABE/ASE ELAA/IELCE
Has participant previously attended
Adult Education classes?
Yes No
PARTICIPANT NAME*
Enter the participant’s LEGAL NAME as it appears on the presented State or Federal identification.
FIRST NAME* ________________________________________________ MIDDLE NAME _____________________
LAST NAME* ___________________________________________________________________________________
DATE OF BIRTH* ____/_____/________ GENDER* Female ☐ Male ☐
MAILING ADDRESS*
Participant’s full street address, including apartment number or “care of” (c/o) information. Please use abbreviations to make sure the
information fits.
STREET ADDRESS, PO BOX, FPO, APO*
_________________________________________________________________________________________________________
CITY* _____________________________ STATE* ____________ COUNTY* ____________________ ZIP CODE* ____________
PHONE NUMBERS* Primary Contact* (_____) __________________ Emergency Contact (_____) _______________
EMAIL* ________________________________________________________________________________________
☐@gmail.com ☐@yahoo.com ☐@hotmail.com ☐@msn.com ☐other@____________________
Do you have internet access? Yes ☐ No☐ Which devices do you own? smartphone ☐ tablet ☐ laptop ☐ other ☐
The US Department of Education requires that we report on the following demographic information:
ETHNICITY* Are you Hispanic/Latino?
Choose only ONE. ☐ YES, Hispanic/Latino ☐ NO, not Hispanic/Latino
RACE* Please choose the best answer(s) from the choices below. If left unmarked, the Program will choose for participant.
☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American
☐ Native Hawaiian or Other Pacific Islander ☐ White
(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
MM DD YYYY
PARTICIPANT SOCIAL SECURITY NUMBER (do not enter dashes)
Workforce Test Date ____/_____/____
MM DD YYYY
(Only applicable if workforce test date is prior to today’s date and will replace
enrollment date from above)
NOTE: Workforce staff must be trained by ADE/AES for tests to be considered.
TO BE FILLED OUT BY STAFF
REGISTRATION - PAGE 2
*denotes required field (FY21 Rev 06/2020) GO TO NEXT PAGE
Do any of the following situations apply?* (Mark Yes or No to each question)
Displaced Homemaker (The parcipant has been providing unpaid services to family members in the home and (a) has
been dependent on the income of another family member but is no longer supported by that income; (b) is the dependent
spouse of a member of the armed forces on acve duty whose family income is signicantly reduced because of (i) a deployment
or a call or order to acve duty pursuant to a provision of law, (ii) a permanent change of staon, or (iii) the service-connected
death or disability of the member; and (c) is unemployed or underemployed and is experiencing diculty in obtaining or upgrad-
ing employment.)
Yes☐ No☐
Long-term Unemployed (The parcipant has been unemployed for 27 or more consecuve weeks)
Yes☐ No☐
Cultural Barrier (A percepon of him-or herself as possessing atudes, beliefs, customs, or pracces that inuence a way
of thinking, acng, or working that may serve as a hindrance to employment)
Yes☐ No☐
Low Income (The parcipant (a) receives, or in the 6 months prior to applicaon to the program has received, or is a member
of a family that is receiving in the past 6 months assistance through the Supplemental Nutrion Assistance Program (SNAP), the
TANF program, the Supplemental Security Income (SSI) program, or State or local income-based public assistance; (b) is in a family
with total family income that does not exceed the higher of the poverty line or 70% of the lower living standard income level; (c)
is a youth who receives, or is eligible to receive, a free or reduced-price lunch; (d) is a foster child on behalf of whom State or local
government payments are made; (e) is a parcipant with a disability whose own income is the poverty line but who is a member
of a family whose income does not meet this requirement; (f) is a homeless parcipant or homeless child or youth or runaway
youth; or (g) is a youth living in a high-poverty area.)
Yes☐ No☐
Ex-Oender (The parcipant is a person who either (a) has been subject to any stage of the criminal jusce process for com-
ming a status oense or delinquent act, or (b) requires assistance in overcoming barriers to employment resulng from a rec-
ord of arrest or convicon )
Yes☐ No☐
Migrant and Seasonal Farmworker (The parcipant is a low-income individual who for 12 consecuve months out of
the 24 months prior to applicaon for the program involved has been primarily employed in agriculture or sh farming labor that
is characterized by chronic unemployment or underemployment and faces mulple barriers to economic self-suciency.)
Seasonal☐
Migrant & Seasonal☐
No☐
Homeless/Runaway Youth (The parcipant lacks a xed, regular, and adequate nighme residence; has a primary
nighme residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodaon for
human beings; is a migratory child who in the preceding 36 months was required to move from one school district to another due
to changes in the parent’s or parent’s spouse’s seasonal employment in agriculture, dairy, or shing work; or is under 18 years of
age and absents himself or herself from home or place of legal residence without the permission of his or her family)
Yes☐ No☐
Individual with a Disability, including a learning disability (The parcipant indicates that he or she has any disa-
bility, dened as a physical or mental impairment that substanally limits one or more of the person’s life acvies, as dened
under the Americans with Disabilies Act of 1990)
Yes☐ No☐
NATIVE LANGUAGE*
English Cambodian Chinese
Spanish German Korean
French Somali Other ______________________
REGISTRATION - PAGE 3
*denotes required field (FY21 Rev 06/2020) GO TO NEXT PAGE
Youth in Foster Care/Aged Out of System (The parcipant is a person who is currently infoster care or has aged out
of the foster care system)
Yes☐ No☐
Exhausng TANF within 2 years (The parcipant is within 2 years of exhausng lifeme eligibility under Part A of Title
IV of the Social Security Act (42 U.S.C. 601 et seq.), regardless of whether he or she is receiving these benets at program
entry.)
Yes☐ No☐
Single Parent (The parcipant is a single, separated, divorced, or widowed individual who has primary responsibility for one
or more dependent children under age 18, including single pregnant women.)
Yes☐ No☐
Refugee (A parcipant who has been forced to leave their country in order to escape war, persecuon, or natural disaster.)
Yes☐ No☐
Living in Rural Area (any populaon, housing, or territory NOT in an urban area with less than 2,500 residents)
Yes☐ No☐
Children in Local School System (A parcipant who has children in the local K-12 school system)
Yes☐ No☐
In Correconal Facility A parcipant that is located in a jail, prison, or other place of incarceraon by government
ocials.)
Yes☐ No☐
In Community Correconal Program (A parcipant that is either on probaon or parole)
Yes☐ No☐
On Public Assistance ☐ Not on Public Assistance☐
If On Public Assistance,
Food Stamps ☐
WIC ☐
Other ☐
In Other Instuonal Seng (A parcipant that is required by court order to reside in an instuonal seng other
than a jail or prison.)
Yes☐ No☐
On Probaon (Granted by the court as part of the convicted oender’s inial sentence. Probaon may be granted in lieu
of any jail me or aer a short period of me in jail.)
Yes☐ No☐
Veteran of the Armed Forces (any person who served honorably on acve duty in the armed forces (Army, Navy,
Air Force, Marine Corps, and Coast Guard) of the United States.)
Yes☐ No☐
Do any of the following situations apply?* (Mark Yes or No to each question)
REGISTRATION PAGE 4
*denotes required field (FY21 Rev 06/2020) GO TO NEXT PAGE
Identify Your Primary Reason for Seeking Adult Education Services* (Mark Yes/No to each question. ONE or
BOTH must be marked as Yes)
I want to learn English
(English Language Learner)
Yes ☐ No☐
I want to improve in Math, English Language Arts,
Science and/or Social Studies.
(Basic Skills Decient/Low Levels of Literacy)
Yes ☐ No☐
EDUCATION AND EMPLOYMENT*
Location of highest grade completed ( Mark only ONE)*: U.S. School ☐ Non – U.S. School ☐
Mark the highest grade range completed*:
No School Completed Grade 5 Grade 10
Grade 1 Grade 6 Grade 11
Completed Some College
Grade 2 Grade 7 Grade 12
Associate’s Degree
Grade 3 Grade 8 Achieved HS Diploma
Bachelor’s Degree
Grade 4 Grade 9 Achieved HS Equivalency
Beyond Bachelor’s
Degree
Mark current employment status*:
Employed Not in the Labor Force
Employed but Received Noce of Terminaon of Employment or
Military Separaon is Pending
Unemployed
HOW DID YOU LEARN ABOUT THE ADULT EDUCATION PROGRAM? (Mark all that apply)
Friend or Family
Member
Website Classmate Military
Recruiter
Newspaper/Magazine Court or Court Or-
der
Employment Counselor
None
Pamphlet or Brochure Union Educaon Agency
Other:
Employer Returning Student Jail/Probaon/Parole
Ocer
Radio or TV Agency Referral Social Worker
Less than $2,500 $12,500 to $12,999 $22,500 to $24,999 $35,000 to $37,499
$2,500 to $4,999 $13,000 to $14,999 $25,000 to $27,499 $37,500 to $39,999
$5,000 to $7,499 $15,000 to $17,499 $27,500 to $29,999 $40,000 to $42,499
$7,500 to $9,999 $17,500 to $19,999 $30,000 to $32,499 $42,500 to $44,499
$10,000 to $12,499 $20,000 to $22,499 $32,500 to $34,999 More than $45,000
Annual Earnings* (Mark only ONE)
ARIZONA@WORK
REGISTRATION PAGE 5
*denotes required field (FY21 Rev 06/2020) GO TO NEXT PAGE
Parcipant Signature* _________________________________________________________ Date ____/____/______
MM DD YYYY
By signing below, I represent that the informaon I have provided in this declaraon and document is true and correct and that any
document(s) I present are genuine. I understand that false or misleading informaon or documents related to this declaraon may
subject me to expulsion from the program as well as other legal acons.
Validity of Informaon
To aend adult educaon programs funded through the Arizona Department of Educaon (ADE), the parci-
pant must allow his or her informaon to be entered into and shared with designated adult educaon data
systems, including the state-mandated tesng plaorm, and all Workforce Innovaon and Opportunity Act
(WIOA) Core Partners’ data systems. This informaon will be shared with any ADE-funded adult educaon
programs in which the parcipant enrolls, the parcipant’s instructors, and the Arizona Department of Edu-
caon. This informaon is used for program operaons, student instrucon, employment opportunies, and
to compile federal and state reports of aggregate student data.
Parcipant Printed Name * _________________________________________________________
Parcipant Signature* _________________________________________________________ Date ____/____/______
MM DD YYYY
Data matching is used to improve program eecveness and increase value to students by measuring performance outcomes including entry to employment,
enrollment in postsecondary educaon and training, and aainment of High School Equivalency diploma. Check this box ☐ if you wish to OPT OUT of State agency
data matching.
MM DD
YYYY
Eligibility for Services
§A.R.S. 15-232(B) states that “The Department of Education shall provide classes under this section only to
adults who are citizens or legal residents of the United States or are otherwise lawfully present in the United
States. This subsection shall be enforced without regard to race, religion, gender, ethnicity or national origin.”
I affirm under penalty of perjury that I am a citizen of the United States, a legal resident of the United States,
or otherwise lawfully present in the United States. Should my status change, I understand that it is my
responsibility to withdraw from classes until such a time that I am again lawfully present in the United
States.
Printed Name as it appears on State or Federal Identification* _______________________________________________________
Participant Signature* _________________________________________________________ Date ____/____/______
MM DD
YYYY
Printed Name of Staff member witnessing Signature* ____________________________________________________________
Witness Signature* _____________________________________________________________ Date ____/____/______
Family Educaonal Rights and Privacy Act Release
REGISTRATION PAGE 6
*denotes required field (FY21 Rev 06/2020)
FOR PROGRAM USE ONLY
Form verified - Verified by: ______________________________________________ Date: _____/_____/_______
Entered into AAEDMS - Entered by: ________________________________________ Date: _____/_____/_______
Returned for Revision - Returned to: ______________________________________ Date: _____/_____/_______
Approved in AAEDMS - Approved by: _____________________________________ Date: _____/_____/_______
Comments/Notes:
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Registration Form (Coconino Community College)

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Completed 25 July 2020

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