English Language Learner Registration

English Class Registration

Please complete the following form in order to start the process of enrolling in classes with Washington Township Adult Education. If you need help filling out this form, we can help you when you come in person to orientation or over the phone. You can translate this form into your native language using the button in the upper right.
What program at Washington Township Adult Education are you interested in enrolling in? *

English Classes (for non-native English Speakers)
Name *

First Name Last Name
Social Security Number or ITTN
(If no SSN, fill in all ones.)
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of residence *
i.e. Marion County
Phone Number *
Please enter a valid phone number.
Your Email *
example@example.com
Your Date of Birth *

Month Day Year
Date
Emergency Contact Phone Number *
Please enter a valid phone number.
Emergency Contact Name *

First Name Last Name
Are you OVER 18 years old? *

Yes No
Gender

Female Male Nonbinary Prefer not to say
Ethnicity

Hispanic Other
Race

American Indian African American Asian Pacific Islander White Other
Native Country
Are you a US Citizen?

Yes No Currently in application process Other
When did you come to the United States?

Month Day Year
Date
If you are not a US citizen, do you have a work permit?

Yes No Working on it Other
Are you currently employed?

Yes No Not in the labor force Other
If you are not in the labor force, what best describes your situation?

I am not eligible for work in the USA I am retired I am a homemaker I am disabled Other
Where do you work?
What is your job title?
Do you work full-time or part-time?

Full-time Part-time
When did you start working at your job?

Month Day Year
Date
What is your current school attendance status?

In high school In college Not in school
What is the highest level of schooling you received?

Grades 1-5 Grades 6-8 Grades 9-12 NO DIPLOMA Certificate of Completion (Disability/IEP) High School Equivalency High School Diploma Some Post-secondary (NO DEGREE) Certification or other non-degree technical program Bachelor's Degree Associate's Degree Master's/PhD Other
Was the last school you attended in the US?

Yes No
Are you currently enrolled in school?

Yes No
If yes, what is the name of your current school?
Do you have any dependents (children under 18) or are you a dependent (under 18)?

Yes No
How many people live in your house, including yourself?
i.e. 3
What is your annual household income?
Have you previously been a student at Washington Township Adult Education?

Yes No
How did you find out about Washington Township Adult Education?

I am a returning student Friend or Family Google online search Facebook or other Social Media Catholic Charities Other
Select any of the following demographics that apply to you:

Veteran Disability (Physical/Mental) Live in an urban area (in the city or within 50 miles of it) Live in a rural area (outside of the city) HIPP/SNAP Recipient Low Income Stay-at-home parent/guardian/caretaker Single Parent Currently laid off or terminated Claims Dependents Foster Care Homeless Non-English used at home Active Military (or military spouse) Vocational Rehabilitation Wagner-Peyser Employment Migrant/Seasonal Farmworker Ex-Offender Cultural Barriers to Employment
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); and the division of Adult Education and the Indiana Department of Education. By signing this form, I understand and agree to the following: 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 and 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. By filing in your full name below you are agreeing to these terms. Please type your name and date below. Students under the age of 18 must have this consent form signed by the student’s parent or guardian. *
Name
I give WTAE permission to share photo images and student approved testimonials on WTAE social media platforms, website, and partnering state agencies. *

Yes No
There is a $20 non-refundable registration fee due on the day of your intake. How would you like to pay?

Cash Check Credit/Debit
Please select the intake date you plan on attending:

October 22,2021 @ 9:45 am October 25,2021 @ 5:30 pm December 17,2021 @ 9:45 am December 20,2021 @ 5:30 pm
Should be Empty:

English Class Registration