STUDENT INFORMATION PROGRAM YEAR 2022-2023
Name* Please carefully type your legal name .
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Middle
Last
Are you a student at the Excel Center (or any other high school)?* PLEASE NOTE: You will not be able to submit this form if you are currently a student with the Excel Center (or any other high school).
Address*
Please upload a favorite photo of yourself so that we can use it for your student ID. County:* Please select the county in which you currently live.
Please select your county. MARION HENDRICKS MORGAN ORANGE KOSCIUSKO MONROE COUNTY NAME EXAMPLE 4 GRANT HAMILTON MADISON TIPTON DELAWARE HOWARD JEFFERSON ALLEN KENTUCKY LAKE PORTER STARKE WARRICK ADAMS BARTHOLOMEW BENTON BLACKFORD BOONE BROWN CARROLL CASS CLARK CLAY CLINTON CRAWFORD DAVIESS DEARBORN DECATUR DEKALB DUBOIS ELKHART FAYETTE FLOYD FOUNTAIN FRANKLIN FULTON GIBSON GREENE HANCOCK HARRISON HENRY HUNTINGTON JACKSON JASPER JAY JENNINGS JOHNSON KNOX LAGRANGE LAPORTE LAWRENCE MARSHALL MARTIN MIAMI MONTGOMERY NEWTON NOBLE OHIO OWEN PARKE PERRY PIKE POSEY PULASKI PUTNAM RANDOLPH RIPLEY RUSH SAINT JOSEPH SCOTT SHELBY SPENCER STEUBEN SULLIVAN SWITZERLAND TIPPECANOE UNION VANDERBURGH VERMILLION VIGO WABASH WARREN WASHINGTON WAYNE WELLS WHITE WHITLEY
Are you a US Citizen?* We accept ALL students, regardless of which citizenship status you choose. Clicking NO will not prevent you from enrolling with us.
Veteran Status* Please select the option that best describes you.
Please select the statement that best describes you. I am not a veteran I am a veteran with less than 180 days of active duty. I am a veteran with at least 180 days of active duty. I am a veteran who served in a war or expedition with an authorized campaign badge.
Country of Birth* Please select your country of birth. UNITED STATES AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA, PLURINATIONAL STATE OF BONAIRE, SINT EUSTATIUS AND SABA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA COTE D'IVOIRE (IVORY COAST) CROATIA CUBA CURACAO CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISLE OF MAN ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI NORTH KOREA (DPRK) SOUTH KOREA KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT BARTHELEMY SAINT HELENA, ASCENSION AND TRISTAN DA CUNHA SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN (FRENCH PART) SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SINT MAARTEN (DUTCH PART) SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SOUTH SUDAN SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA, BOLIVARIAN REPUBLIC OF VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE KOSOVO SCOTLAND VIETNAM YUGOSLAVIA Ivory Coast TIBET MAURITANIA NORTH MACEDONIA CABO VERDE ESWATINI
Date of Birth* Gender* Ethnicity* NOTE: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race, refers to Hispanic ethnicity. Please select the option below that describes your ethnicity.
Please select the ethnicity that best describes you. Hispanic Other
Race:* Please select all that apply.
Name of Emergency Contact:* Who can we contact if we cannot reach you?
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Last
Employment Information Employment Status: (Choose the one that best describes you.)* Date of Hire*
Educational Information Educational Status:* Please check the highest level of education you have completed.
Last Grade Completed* Please choose the last grade level (1-12) that you completed. *If you have completed education beyond high school, you will choose 12 as your last grade level completed.
Previous Schooling Location:* Where did you complete most of your schooling so far?
School Attendance Status at Entry:* Select the option that BEST describes your current school situation:
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Current Enrollment Type: For which reason are you interested in coming to school?
Resident Institution:* Please select the option that best describes your CURRENT residential situation.
Method Found:* Please select the answer that best describes how you first learned about our program.
Select the method in which you found us. FRIEND,RELATIVE TV OR RADIO NEWSPAPER BROCHURE, FLYER DEPT WORKFORCE DEV PUBLIC ASSIST REFER LIT. PGM REFERRAL COURT REFERRAL OTHER REFERRAL EMPLOYER SHELTER OTHER METHOD DWD WEBSITE WORKONE REFERRAL LOCAL ABE PROGRAM WEBSITE
Demographics Do you have any impairments (physical, mental or learning)? Do you live in an urban area (inside the city)?* Do you live in a rural area (outside city)?* Do you currently receive public assistance?* Organizations such as Temporary Assistance For Needy Families (TANF), SNAP (food stamps), SSI and WIC are examples of public assistance.
Do you believe that you have a low level of income?* This means that you do not believe you have enough income to pay your bills.
Are you a displaced homemaker?* This means you were previously a homemaker, but now seeking work due to a change in your household status.
Are you a single parent?* Are you a dislocated worker?* This means that you lost your job due to layoffs or your company moving out of the country.
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Are you a Dependent or do you have Dependent(s)?* This means that you are claimed as someone's dependent on taxes OR you claim dependents on your own taxes.
Are you currently, or have you ever, been in foster care?* Are you homeless, or are you a runaway?* This means that you DO NOT have a permanent, regular nighttime residence (other than a vehicle, a shelter, or temporarily staying with a friend).
Do you speak a language other than English at home?* Hidden
Annual Family Income (yearly income before taxes): We are asking this information for the purpose of finding resources for you. We accept all students, regardless of family income.
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Annual Family Income (yearly income before taxes):* We are asking this information for the purpose of finding resources for you. We accept all students, regardless of family income.
0-1000 1001-2000 2001-3000 3001-4000 4001-5000 5001-6000 6001-7000 7001-8000 8001-9000 9001-10000 10001-15000 15001-20000 20001 or more
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Household Size* How many people live in your household, including yourself?
Are you a dependent yourself, or do you claim to have dependent(s) in your household?* A YES response means that either someone claims you as a dependent OR you claim to have dependent(s) yourself.
Annual Family Income (How much is your family income in one year?* What is the language you first learned as a child?* Select your first language. English Afrikaans Albanian Amharic Arabic Armenian Azerbaijani Basque Belarusian Bengali Bosnian Bulgarian Catalan Cebuano Chichewa Chinese Corsican Croatian Czech Danish Dari Dutch Esperanto Estonian Filipino Finnish French Frisian Galician Georgian German Greek Gujarati Haitian Hausa Hawaiian Hebrew Hindi Hmong Hungarian Icelandic Igbo Indonesian Irish Italian Japanese Javanese Kannada Kazakh Khmer Korean Kurdish Kyrgyz Lao Latin Latvian Lithuanian Luxembourgish Macedonian Malagasy Malayalam Malay Maltese Maori Marathi Mongolian Myanmar/Burmese Nepali Norwegian Pashto Persian Polish Portuguese Punjabi Romanian Russian Serbian Shona Sesotho Sindhi Sinhala Slovak Slovenian Samoan Scots Gaelic Somali Spanish Sundanese Swahili Swedish Tajik Tamil Telugu Thai Turkish Ukrainian Urdu Uzbek Vietnamese Welsh Xhosa Yiddish Yoruba
We have many resources to help our students overcome barriers that might make it difficult to come to school. Please select any of the issues listed below that apply to you, as we may be able to help! Select all that apply.* Migrant/Seasonal Farm Worker:* Please select the option that best describes you:
Are you Active Military?* Please select the answer that best describes you:
Are you involved in a Vocational Rehabilitation agency?* Please select the option that best describes you.
Do you utilize Wagner Peyser Employment services?* Wagner-Peyser employment services refers to federally-funded Unemployment Services, which connects employers with job seekers.
Ex-Offender* Have you ever been convicted of a crime?
Cultural Barriers to Employment* Do you believe that you have any cultural barriers that affect your job opportunities?
Do you have a computer or laptop?* Does your computer or laptop have a camera?* Do you have internet access at home?*
Release of Information I am enrolling in an Adult Basic Education (ABE) program. This ABE program works with the following programs and agencies to help students improve their skills and earn better jobs:
• Other state-funded adult education programs
• WorkOne offices and job training programs
• Public and private colleges
• State executive offices, departments, and agencies, including the Indiana Department of Workforce Development (IDWD), Division of Adult Education and the Indiana Department of Education.
By signing below, I understand and agree to the following:
• The information on my intake form is correct.
• DWD use of directory information (name, address, birth, and social security number) to match test score records, wage information, and college/training program enrollment records that assist the state to evaluate and improve its programs and to report results to the federal and state government.
• The sharing of information between the agencies and programs listed above. This information may include my name, enrollment information, education/career goals, test scores, HiSET test account information and scores, and employment history. The information will be kept strictly confidential and will be used for program administration, research, and evaluation purposes.
I agree to the Release of Information described above.* Photo Release We love to celebrate success with our students, and we often do that through pictures, articles, slideshows, and other fun media. In order for you to participate in that, we will need permission to use your photo.
I grant Wayne Township Adult Education, its representatives and employees the right to take and/or use provided photographs of me in connection with documents and promotional materials published by the same. I authorize MSD of Wayne Township Adult Education, its representatives and employees, to use and publish the same in print and/or electronically.
I agree that Wayne Township Adult Education may use such photographs of me with or without my name for purposes including training and instruction manuals, promotional materials, and electronic documents.
Student Photo Release* Student Contract/Code of Conduct Please review our Student Contract, which can be found at the following link. The link will open in a new tab, so please make sure to come back to this tab to finish signing this form.
adulted.info/students Student Contract Agreement* I have read, and I agree to abide by, the rules in the Wayne Township Adult Education Student Handbook, which can be found at adulted.info/students for current and future reference.
Enrollment Verification Request Please let us know if you need verification of your school enrollment.
Will you need a letter of enrollment verification sent to another agency?* You may request a letter of enrollment verification be sent to other agencies under the following conditions:
✓ you have at least 12 hours of attendance
✓ you understand that Wayne Township Adult Education staff members needs 2-3 business days to process this request
✓ you give permission for Wayne Township Adult Education to share this information
✓ you provide the contact information requested below
Agency Address*
Contact Name*
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Electronic Signature Typing your name in the fields below will constitute your electronic signature(s) for the above provided information. Please verify that all information is accurate before you sign. Applicants who are under 18 years of age will require a parent/guardian signature as well.
Today's Date* Please type today's date as the date you are verifying your information above.
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