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Thank you for your interest in taking Wayne Adult Education classes for the 2020-21 school year! Whether you are interested in learning English, High School Equivalency (HSE), or career training, everyone starts here!

Please enter your information on the form below.

Step 1 of 8 - Background

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STUDENT INFORMATION
ACADEMIC YEAR 2020-21
I am enrolling in the following program:*
- ELL (English Language Learning) classes - I need to learn English.
- ABE (Adult Basic Education) / HSE (High School Equivalency) classes - I need a High School Equivalency OR I already have a diploma, but am seeking career training.
Name*
First Middle Last
Have you ever attended an ELL (English Language Learning) program before?*
- Yes
- No
What was the name of the school?*
In what year were you enrolled in the ELL (English Language Learning) program?*
Have you ever attended an ABE (Adult Basic Education) or HSE (High School Equivalency) program before?*
- Yes
- No
What was the name of the program?*
In what year were you enrolled in the ABE (Adult Basic Education) or HSE (High School Equivalency) program?*
Are you an Excel Center student?*
- Yes
- No
NOTE: You will not be able to submit this form if you are currently an Excel Center student.
Thank you for applying for adult education funding. Unfortunately, any student that is K-12 enrolled is not eligible for adult education. According to the Department of Workforce Development, Excel is a K-12 school. Students that want adult education classes must be formally exited from their school. If you wish to exit your current program download and complete this form.
Student Information
Address*
Street Address City State ZIP Code
Do you have a home phone?*
- Yes
- No
Home Phone Number*
Do you have a cell phone?*
- Yes
- No
Cell Phone Number*
Do you prefer to be contacted via text message?*
- Yes
- No
Do you have an email address?*
- Yes
- No
Email Address:*
Make this an email you check often.
I live in:*
- Marion County
- Hendricks County
- Morgan County

EMERGENCY CONTACT INFORMATION
Emergency Contact's Name*
First Last
Emergency Contact's Phone*
Relationship to you:*
- Spouse/Significant Other
- Parent
- Legal Guardian
- Other family member
- Friend

Student Information
DATE OF BIRTH*
Age (Choose the description that fits you.)*
- 16-17
- 18 or older
To enroll, a 16 or 17-year-old student must have a signed exit interview from his/her school district upon registration with us. We also need parent or guardian signatures, so parents/guardians need to accompany their 16 or 17-year-old children for registration.

Click Here to Download Exit Interview Form
Gender*
- Male
- Female
Maiden Name (only for females who had a different last name before they were married)
Do you have children in K-12 Schools?*
- Yes
- No
Which school district(s)?*
- Avon
- Brownsburg
- Danville
- Plainfield
- Tri-West
- Mill Creek
- Mooresville
- Monrovia
- IPS
- Speedway
- Decatur
- Wayne
- Other
Other school district:*
Which MSD Wayne Township school does your child(ren) attend?*
Do they receive ELL services?*
- Yes
- No
ETHNICITY:*
- Hispanic
- Other
NOTE: Your ETHNICITY describes the social group to which you belong that shares a common and distinctive culture, religion, or language.
RACE: (Check all that apply.)*
- African American
- Pacific Islander
- American Indian
- White
- Asian
NOTE: Your race describes the group of people to which you belong who shares similar and distinct physical characteristics.
COUNTRY OF BIRTH:*
Are you a US Citizen?*
- Yes
- No
Is English your first language?*
- Yes
- No
What is your first language?*
- Amharic
- Arabic
- Chinese
- French
- Korean
- Mandarin
- Punjabi
- Portuguese
- Somali
- Spanish
- Tigrinya

Employment Information
Did you experience a job loss due to COVID-19?*
- Yes
- No
Did you experience a job loss due to your company relocating out of the country?*
- Yes
- No
Employment Status: (Choose the one that BEST describes you.)*
- Employed
- Unemployed
- Not working, not looking for a job, not in the labor force
- Employed, termination/separation pending
- Unemployed more than 26 weeks
Employer Name:*
Date hired:*

Educational Information
Check your highest level of education:*
- No formal school
- Grades 1-5
- Grades 6-8
- Grades 9-12 (no diploma)
- Certificate of Completion (Disability/IEP)
- High Shcool Diploma / Alternative credential
- HSE (High School Equivalency) / GED
- Some postsecondary (no degree)
- Certificate / License (no degree)
- Associate's Degree
- Bachelor's Degree
- Beyond Bachelor's Degree
- Unknown
School attendance status at registration: Choose the one that BEST describes you. (Most of our students are #4 or #5.) HINT: #4 means you do NOT have a diploma, GED, or HSE. #5 means you already have a diploma, GED, or HSE. #6 means you are 16 or 17 years old and are out of school.*
- 1 - In-school: Secondary School or less
- 2 - In-school: Alternative School
- 3 - In-school: Attending Postsecondary
- 4 - Not attending high school; out of school; drop-out
- 5 - Not attending high school; student has a high school diploma or college diploma or HSE from the United States or from his/her native country
- 6 - Not attending school within the age of compulsory attendance for 16-17 year olds
Previous schooling location:*
- U.S.-based schools
- non-U.S.-based schools
Last grade completed:*
Enter your highest grade level you completed. If you attended a postsecondary training program or college, enter "12+".
Last school attended:*

I currently live in:*
- Community Corrections Facility (half-way house)
- Correctional Facility (jail/prison)
- Medical/Group/Nursing (nursing home)
- None of these
Required for State Funding
PART A: DEMOGRAPHICS
Do you have an impairment or disability?*
- Yes
- No
Type of impairment or disability:*
- Select All
- Physical
- Mental
- Learning
Have you ever had an Individualized Education Program (IEP)?*
- Yes
- No
- Not Sure
Select the type of area in which you live:*
- Urban (Housing, businesses, and shopping are close to you)
- Rural (Fields, forests, and no businesses or shopping are near you.)
Do you receive public assistance? **This includes government assistance such as SNAP (food stamps), TANF (Temporary Assistance for Needy Families), etc.*
- Yes
- No
Low Income (This means that you believe you do not earn enough money to pay bills, etc.)*
- Yes
- No
Are you a displaced homemaker? (This means that you had to go back to work because your spouse left home.)*
- Yes
- No
Are you a single parent? (This means that you are the custodial single parent.)*
- Yes
- No
Are you a dislocated worker? (This means that you lost your job through a layoff or closing.)*
- Yes
- No
Required for State Funding
PART B: DEPENDENT OR HAS DEPENDENT(S)
You claim children on your tax forms, or you are claimed on someone else's tax forms as a dependent.*
- Yes
- No
Annual family income (yearly income before taxes):*
Household size (number of people living with you, including yourself):*
Do you have a HIP (Healthy Indiana Plan) card?*
- Yes
- No
- I don't know
Required for State Funding
PART C: DEMOGRAPHICS
Foster Care Youth (Are you currently in the foster care system, or have you been in the foster care system?)*
- Yes
- No
Homeless / Runaway (Are you homeless and/or do you currently have no place to live?)*
- Yes
- No
Non-English spoken at home (Is a language OTHER THAN ENGLISH the primary language in your home?)*
- Yes
- No
Migrant Worker (Are you a seasonal farm worker?)*
- Yes
- No
Active Military (Are you or your spouse on active duty status?)*
- Yes
- No
Required for State Funding
PART D: DEMOGRAPHICS
Vocational Rehabilitation (Have you received services for disabilities?)*
- Yes
- No
Wagner Peyser Services (Are you receiving WorkOne Employment Services?)*
- Yes
- No
Ex-Offender (Have you have been arrested or convicted?)*
- Yes
- No
Cultural Barriers (Do you believe that your attitudes, religion, customs, skin color, or dress have affected your job opportunities?)*
- Yes
- No

How did you hear about our program? (Check all that apply.)*
- brochure/flyer
- court referral
- Department of Workforce Development
- adulted.info website
- employer
- friend/relative
- newspaper
- public assistance referral
- shelter
- TV/Radio
- WorkOne referral
- Robocall
- Email
- Social Media (Facebook, Instagram, Twitter, etc)
- Other
Enrollment Verification
Do you need a letter of enrollment verification sent to other agencies?*
- Yes
- No
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
Contact #1 - Agency Name*
Contact #1 - Contact Name*
Contact #1 - Title*
Contact #1 - Agency Address*
Contact #1 - Agency City*
Contact #1 - Agency Zip Code*
Contact #1 - Email Address*
Contact #1 -Phone*
Contact #1 -Fax
Contact #2 - Agency Name
Contact #2 - Contact Name
Contact #2 - Title
Contact #2 - Agency Address
Contact #2 - Agency City
Contact #2 - Agency State
Contact #2 - Agency Zip Code
Contact #2 - Email Address
Contact #2 -Phone
Contact #2 -Fax

Release of Information
I am enrolled in an adult education (AE) program. This AE 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 (DWD), 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, 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 above information*
- Yes
Signature*
Please type your full name.
Parent/Guardian Signature*
Please type your full name.
Code of Conduct
I have read, and I agree to abide by, the rules in the Wayne Township Adult Education Code of Conduct as described in the student handbook found at adulted.info/students and in the resources section of this enrollment portal. I also understand that I can access the Wayne Township Adult Education Student Handbook on adulted.info/students for future reference.*
- Yes
Signature*
Please type your full name.
Parent/Guardian Signature*
Please type your full name.
Photo Release
I give permission for Wayne Township Adult Education to use my name and photo on online or print promotional communication.*
- Yes
- No
Signature*
Please type your full name.
Parent/Guardian Signature*
Please type your full name.
Please write in your Social Security number below (This is helpful to us, but not required):

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