Registration Form for Adult Education Classes

Procedures and Releases for Participant:
Participant Name : *
Participant Release of Information

The information provided is complete and correct to the best of my knowledge. I agree to abide by Adult Education Program policies, rules and regulations. I further understand the submission of false information is grounds for rejection of my application, withdrawal of acceptance, and cancellation of enrollment. My signature below shall constitute acknowledgement to statistical use of my records of enrollment, progress, credential obtainment, and transition to postsecondary enrollment or employment. My signature below also authorizes use of my personally identifiable information, including my employment and wage information pre-, during and post- enrollment for audit, study and evaluation of the Adult Education and Literacy program performance and other state and federally-funded programs.

Such programs may include but are not limited to those under the laws administered by the (THEBC) Texas Education Agency and the (TEA) Texas Higher Education Coordinating Board.

I acknowledge that the Adult Education and Literacy program and that TWC may release personal identifiable information to other local, state, federal, partners and/or stakeholders for verification of state and federal program requirements, performance reporting, audit, evaluation, study and to monitor the programs performance.

Participants who are 17 and 18 years of age must have written parental permission or qualify for another exemption from compulsory attendance law.

**Please note that if you do not check the boxes below, to share data, you will not be allowed to enroll into the AE classes – this is a requirement for participation in the program.

Do not release Directory Information

	Yes	No
Share Data with the THEBC
Share data with TEA

***Complete the signature below using your mouse or touchscreen if you are using a touch enabled device.
Print Name
Participant Signature *

Clear
Date *

Month Day Year
Date
Print Name
Parent/Guardian Signature (if participant is 17 or 18 year old)

Clear
Date

Month Day Year
Date
Story/Photo/Video Releases
I understand that when I participante in events or activities at CAI associated centers (Head Start, Early Head Start, Senior Citizen, Adult Education, Community Services, Health Services and Career Pathways), that I may be depicted in a photographic work or recorded in a video. CAI may use, reproduce, publish and redistribute any stories, photograph(s) or videos, either complete or in part, alone or in connection with reports, publications, promotional materials and pages of the web site or related pages, Facebook account and Twitter account whether now known or later invented to promote public awareness of CAI's goals.
*

Yes, I give CAI permission for my stories, photograph(s) and or video(s) to be used for these purposes. I understand that I do not own the copyright of the stories, photograph(s) and/or video(s). I certify that I am over 18 years of age (or this agreement is co-signed by my parent/guardian). No, I do not give CAI permission to use my stories, photograph(s) and or video(s).
Adult Education Program Guidelines for Attendance, Classroom and Code of Conduct
Orientation/Enrollment
All participants must complete a New Participant Orientation and complete enrollment paperwork before attending classes. After completing orientation and enrollment paperwork, participants may attend classes and/or transfer to classes in another CAI center.

Class sign-in sheets
Participant hours are important to the program. Our services are based on participant enrollment and attendance. Please print your name clearly on sign-in sheets. Always use the same name that is on your picture ID or in your record.

Attendance
Participants are expected to attend class regularly. Be prepared for class and use your time in the classroom wisely. If you are unable to attend class, for any reason, you must notify your teacher or program staff. Remember, attendance is crucial to your successfully reaching your goals.

Children
The program provides classes for adults only. Please arrange childcare for your children.

Phone Use
Please turn your cell phone to vibrate or off while you are in class. No text messages or calls are allowed during class. Please leave your classroom if you need to return a call or text message.

Smoking
You are not allowed to smoke in or around the classroom or building. You may return to your vehicle to smoke. Smoking in other areas may be cause for dismissal from the program.

Computer Usage
No one is allowed to install or modify software or hardware on any classroom computers.

Behavior
Participants must behave in a responsible manner, show respect for self and others, cooperate with teachers and Learning Center staff and dress appropriately.

Emergency Procedures
If an emergency situation occurs, please follow the direction of the teacher or staff member and exit classroom/building as directed or shelter in place.
Grievance Procedure
A. Purpose:

The purpose of this document is to lay out an effective process for Community Action Adult Education participants to follow when the experience problems concerning their well-being or the well being of others while in the program. All particpants in the program are encouraged to discuss the issues of concern with administration if they have a complaint or feel they are being treated unfairly. Misunderstanding or conflicts can arise in any organizational setting and should be resolved before serious problems develop. Most incidents resolve themselves naturally, however, in the event that a problem persists, that the participant believes is detrimental to him/herself or the prgram, the following four step process will be used until all levle of authority have been exhausted.

B. Process:

When a participant , parent or person from the community has a complaint with the Adult Education Program or any Adult Education staff, the following steps can be taken. At any time a participant may ask someone to act as an advocate to help them. The role of the Adult Education Staff is to support and guide the particpant while encouraging them to speak for themselves. The grievance procedures should be followed in the order below.

1. Talk with the participnat or staff person you are having the concern with to try and resolve the issue.

2. If the issue is not resolved talk with the instructor or staff supervisor to resolve the issue.

3. If the issue is not resolved talk with the Adult Education Director, Doug Mudd, 512-392-1161 x 332 to resolve the issue.

4. If the issue is not resolved talk with the Executive Director, Caroled Belver, 512-392-1161 x 328.
By signing below I agree to follow and abide by the procedures detailed above.
Participant Signature *

Clear
Date *

Month Day Year
Date
Parent/Guardian Signature (if participant is 17 or 18 year old)

Clear
Date

Month Day Year
Date

	Very Important	Important	Not Important
English Grammar
Reading stories or books
Your home
Money and shopping
Personal health
Helping children with homework
Going to college
Email
Finding a job
Performing well at work
Community and volunteering
U.S. history and government
Passing the citizenship test
Using computers for English practice
For school
For work

Procedures and Releases for Participant: