Arizona Adult Education Participant Registration 2024-2025

Arizona Adult Education Participant Registration
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."
Please mark only one eligibility option. If you are not sure about your eligibility, please consult program staff.*

I am a citizen of the United States of America.I am a legal resident of the United States of America.I am lawfully present in the United States of America for another reason.None of the above
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 Identification presented*
Participant Signature*

Clear
Date*

MonthDayYear
Date

Validity of Information
By signing below, I represent that the information I have provided in this declaration and document is true and correct and that any document(s) I present are genuine. I understand that false or misleading information or documents related to this declaration may subject me to expulsion from the program as well as other legal actions.
Participant Signature*

Clear
Date*

MonthDayYear
Date
Family Educational Rights and Privacy Act Release
To attend adult education programs funded through the Arizona Department of Education (ADE), the participant must allow his or her information to be entered into and shared with designated adult education data systems, including the state-mandated testing platform, and all Workforce Innovation and Opportunity Act (WIOA) Core Partners’ data systems. This information will be shared with any ADE-funded adult education programs in which the participant enrolls, the participant’s instructors, and the Arizona Department of Education. This information is used for program operations, student instruction, employment opportunities, and to compile federal and state reports of non-identifying aggregate student data.
Participant Printed Name*
Participant Signature

Clear
Date

MonthDayYear
Date
The adult education program is required to collect post-exit outcome data in the areas of employment, entry into postsecondary education or training, and attainment of secondary diplomas. This is typically done through data matching with State agencies and educational institutions. The alternative to gathering this information through data match is contacting former students directly, such as by phone or email. If you wish to opt out of data match and instead be contacted after exiting the adult education program choose "Yes".*

NoYes
Adult Education Registration Form
Term*
Student ID Number
First Name & Middle Initial*
Last Name*
Admission Level

ABE/ASE
My signature below verifies my acceptance that I have reviewed and understand the policies associated with enrolling in courses at CCC. I understand Coconino Community College may request documentation from me to confirm the information I have provided.
Registrant's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: