Register – Wayne Township Adult Education Portal

Thank you for your interest in taking Wayne Adult Education classes for the 2022-2023 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.

"*" indicates required fields

STUDENT INFORMATION

PROGRAM YEAR 2022-2023

Student ID

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Initial Application Date:

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Updated Application Date:

Name*

Please carefully type your legal name.

Social Security Number:

We do not require you to provide your social security number, but providing it helps us to track your accomplishments as well as any resources we might be able to provide for you. As always, we keep all of our data secure.

Are you a student at the Excel Center (or any other high school)?*

Yes

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).

According to Indiana state policy, students who are currently enrolled in a high school cannot also be enrolled with us.
If you wish to exit your current program so that you may join our program, click here to download and complete the required exit form., then turn the completed form in to our office.

Address*

Please upload a favorite photo of yourself so that we can use it for your student ID.

Max. file size: 64 MB.

County:*

Please select the county in which you currently live.

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.

Yes

Veteran Status*

Please select the option that best describes you.

Country of Birth*

Mobile Phone Number*

We communicate important messages to students via text message. If you do not currently have a mobile phone, please list a phone number of a trusted family member or friend so that you can receive messages.

Home Phone Number

If a mobile phone number is all you have, this field is not required.

Email:*

Enter an email address you can access easily and check frequently. If you do not have an email, click here for instructions on how to create one..

Date of Birth*

Age:

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

To be able to take the test to earn a High School Equivalency diploma, a 16 or 17-year-old student will also need a Superintendent's Recommendation form signed by his/her school district's Superintendent before he/she can test with us. If you are unable to obtain that Superintendent's signature, let us know and we can help get it completed.

Click here to download the Superintendent's Recommendation form.

Gender*

Male

Female

Other

Please list any other legal names you have had in the past.

For example, if you are married and your last name has changed, list your previous last name here. If you have never had a different name, you can skip this question.

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.

Race:*

Please select all that apply.

African American

Asian

American Indian

Pacific Islander

White

Name of Emergency Contact:*

Who can we contact if we cannot reach you?

First Last

Emergency Contact's Phone Number*

Employment Information

Employment Status: (Choose the one that best describes you.)*

I am NOT IN THE LABOR FORCE, as I am not working, not able to work, or not looking for a job.

I am able to work but am currently NOT EMPLOYED.

I have been UNEMPLOYED FOR MORE THAN 26 WEEKS.

I am EMPLOYED, BUT MY JOB IS BEING TERMINATED.

I am EMPLOYED.

Employer:*

Employer Phone:

This field is not required.

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.

Last School Attended:*

Please type the name of the last school you attended.

Previous Schooling Location:*

Where did you complete most of your schooling so far?

U.S.-based schools

Non-U.S.-based schools

School Attendance Status at Entry:*

Select the option that BEST describes your current school situation:

In-school: Grades k-12

In-school: Alternative School

In-school: Postsecondary (beyond 12th grade)

Not attending school: 18 or older and did not not finish high school

Not attending school: Earned high school diploma or equivalent

Not attending school - Under 18 years old and did not finish high school

Household Information

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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.

Correctional Facility

Community Corr. Facility

Medical/Group/Nursing Home

None of these apply to me.

Method Found:*

Please select the answer that best describes how you first learned about our program.

Demographics

Do you have any impairments (physical, mental or learning)?

Yes

Do you live in an urban area (inside the city)?*

Yes

Do you live in a rural area (outside city)?*

Yes

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.

Yes

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.

Yes

Are you a displaced homemaker?*

This means you were previously a homemaker, but now seeking work due to a change in your household status.

Yes

Are you a single parent?*

Yes

Are you a dislocated worker?*

This means that you lost your job due to layoffs or your company moving out of the country.

Yes

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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.

Yes

Are you currently, or have you ever, been in foster care?*

Yes

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).

Yes

Do you speak a language other than English at home?*

Yes

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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.

Please enter a number greater than or equal to 1.

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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.

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Household Size*

How many people live in your household, including yourself?

Please enter a number greater than or equal to 1.

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.

Yes

Household Size: How many people live in your household, including yourself?*

We accept ALL students, regardless of family income.

Annual Family Income (How much is your family income in one year?*

What is the language you first learned as a child?*

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:

No, I am NOT a migrant farmworker.

I am a migrant farmworker.

I am a migrant AND seasonal farmworker.

I am the dependent of a migrant farmworker.

Are you Active Military?*

Please select the answer that best describes you:

Yes, I am active military.

No, I am not active military.

I am the spouse of someone who is active military.

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.

Yes

Unknown

Ex-Offender*

Have you ever been convicted of a crime?

Yes

Unknown

Cultural Barriers to Employment*

Do you believe that you have any cultural barriers that affect your job opportunities?

Yes

Unknown

Do you have a computer or laptop?*

Yes

Unknown

Does your computer or laptop have a camera?*

Yes

Unknown

Do you have internet access at home?*

Yes

Unknown

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.*

Yes

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*

I agree to the above photo release statement.

I do not agree to the above photo release statement.

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.

Yes

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?*

Yes

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 Name:*

Agency Address*

Street Address City State ZIP Code

Agency Phone*

Agency Email*

Contact Name*

First Last

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.

Signature*

Please type your full name, as this will serve as your electronic signature. This signature acknowledges that the information provided in this form is correct.

Today's Date*

Please type today's date as the date you are verifying your information above.

Parent/Guardian Signature*

Parent/Guardian, please type your full name, as this will serve as your electronic signature. This signature acknowledges that the information provided in this form is correct.

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Program Year

20202021

20212022

20222023

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Program ID

[ABE_45] ABE Program MSD Wayne Twnshp