Student Placement Services Application

ADULT EDUCATION & LITERACY STUDENT ENROLLMENT FORM 2023-2024
What program are you interested in?*

I need my high school equivalency (GED or HiSET)I am interested in preparing for college or preparing for the TSI or TEAS testsI am interested in a Career Training programI want to improve my EnglishI want to improve my Basic SkillsI am Interested in College Support
Have you attended another adult education class?*

YesNo
I. Personal Data

Tell us about yourself
Full Name*

First NameMiddle NameLast Name
Birthdate*

MonthDayYear
Gender*

MaleFemale
Are you Hispanic/Latino?*

YesNo
Race

American Indian or Alaska NativeAsianBlack/African AmericanNative Hawaiian/Other PacificWhite
Identification Information
Do you have a Social Security Number?*

YesNo
You MUST COMPLETE and upload all of your documentation for your application to be processed. For any questions about this application, call us.
Upload your Government Issued Photo ID or DL*

If you don't have an ID or DL, attach your Birth Certificate or another Identity document like (Passport, Matricula, etc...)
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Upload your High School Diploma or GED*

Workforce Training. Example. CNA, Admin, Phlebotomy, etc...
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Upload your Withdrawal Paperwork*

Ages 16-18 only. If 18 and completed High School, upload your H.S. Diploma.
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Contact Information
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email *
Where the confirmation will be send to
Mobile No*
Home No
Do you have internet at home?*

YesNo
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Participant Status Upon Program Entry
Equal Opportunity Information
Do you have a physical or mental impairment that substantially limits one or more of your major life activities?*

YesNoDoes not self-identify
Veteran Information
Are you currently serving in the United States Armed Forces?*

YesNo
Have you served in the United States Armed Forces and been discharged or released from such service under conditions other than dishonorable?*

YesNoStatus Unknown
Do you meet any of the following criteria? 1. Spouse of any person who died on active duty or of a service connected disability; 2. Spouse of any member of the Armed Forces serving on active duty who at the time of application for assistance under this part, is listed, pursuant to 38 U.S. C 101 and the regulations issued there under, by the Secretary concerned, in one or more of the following categories and has been so listed for more than 90 days: (i) missing in action; (ii) captured in the line of duty by a hostile force; or (iii) forcibly detained or interned in the line of duty by a foreign government or power; 3. Spouse of any person who has a total disability permanent in nature resulting from a service connected disability, or the spouse of a veteran who died while a disability so evaluated was in existence. *

YesNo
Employment and Education Information
Employment Status*

EmployedEmployed but will separate (within 12 months) OR retire (within 24 months) from the U.S. Armed ForcesNot EmployedNot looking for work and Not Employed (Not in the Labor Force)
Do you live in a rural or urban location?*

Rural AreaUrban Area
School Status at Program Entry*

I am under 19 years of age, did NOT receive a diploma or equivalency, and I am NOT currently attending schoolI am 19 years of age or older and I did NOT receive a diploma or equivalencyI received my high school diploma or equivalency (GED)I am currently enrolled in college
Highest School Grade Completed*

123456789101112No school grades completed
Highest Education Level Completed*

Attained secondary school (high school) diplomaAttained secondary school (high school) equivalencyParticipant with a disability & attained a certificate of attendance/completion as a result of successfully completing an IEPParticipant with a disability & attained a certificate of attendance/completion as a result of successfully completing 1 or more years of postsecondary educationCompleted one or more years of post-secondary educationAttained a post-secondary certification license, or educational certificate (non-degree)Attained an Associate's degreeAttained a Bachelor's degreeAttained a degree beyond Bachelor's degreeNo educational level completed
Where did you complete your education?*

Completed IN the U.S.Completed OUTSIDE U.S.
Migrant and Seasonal Farmworker Characteristics
Are you a seasonal farmworker whose agricultural labor requires travel to a job site such that makes you unable to return to your permanent place of residence with the same day?*

YesNo
Are you a low-income individual (i) who for the 12 consecutive months out of the 24 months prior to application for the program involved, has been primarily employed in agriculture or fish farming labor that is characterized by chronic unemployment or underemployment; and (ii) faces multiple barriers to economic self-sufficiency?*

YesNo
MSFW Youth: Are you a migrant farmworker or seasonal farmworker (as above) aged 14-24?*

YesNo
Dependent adult: Are you an adult program participant and a dependent of the individual described as a seasonal or migrant seasonal farmworker?*

YesNo
Dependent youth: Are you a youth program participant and a dependent of the individual described as a seasonal or migrant seasonal farmworker?*

YesNo
Additional Program Information
Are you a participant in one of the following programs?*

Family Literacy ProgramWorkplace Literacy ProgramParticipant in Job & Training ProgramNone of these apply to me
Were you referred by WSA?*

One Stop Center ReferralTANF ReferralDoes not apply to meDoes not wish to disclose
Were you referred from a college?*

YesNo
Were you referred by Ready to Work?*

YesNo
How did you hear about Student Placement Services?*

Friend or Family Member (please specify)WebsiteFlyersHigh School or CounselorSocial MediaCollege (please specify)GoogleStreet BannerOther Agency (please specify)
Additional Information
Do you have reliable transportation to school?*

YesNo
How many hours can you commit to attending per week?*

8-12 hours13-16 hours17-20 hours21+ hours
Would you be the first of the family to attend college?*

YesNo
What is your individual annual income?*
ONLY include the yearly income earned by you. If you have no income, enter zero.
What is your household annual income?*
Include the yearly income earned by you and others in your household. If your household has no income, enter zero.
Upload your Household Income proof

REQUIRED for Ready to Work applicants going into Workforce Training.
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What are your educational and career goals?*
Participant Acknowledgement, Release of Information, and Signature
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.
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 Texas Education Agency and the 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.

Additional information may be found at: http://www.twc.state.tx.us/twc-website-privacy-security-information#confidentiality.
Participants who are 16 through 18 years of age must have written parent/guardian permission to participate in the program. Parents/guardians, by signing below, you are verifying that information on this enrollment form is correct, giving your child permission to be part of our Adult Education program, and acknowledging release of information.
Photo & Video Release

I hereby grant and authorize Restore Education the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of Restore Education and will not be returned. I hereby hold harmless, and release Restore Education from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.
City of San Antonio Workforce Development and Department of Human Services release (if applicable)

I understand that if I am an eligible GED applicant, and if I am a resident of the City of San Antonio and eligible to work, I will be automatically screened for and enrolled in the new GED to Work (GTW) incentive program. This new program will allow you to earn incentives for each GED exam passed, while remaining in your regular classroom.

I understand that if I am eligible GED, College, or Career Training applicant, and if I am a resident of the City of San Antonio, I will be automatically screened for and enrolled in the new ARPA program.

If you do not want to participate, please email outcomes@restoreeducation.org.

Consent for Case Management - Release

As a student of Restore Education, I agree to participate in the Case Management Program offered by Restore Education and its partners.

I understand that this means:

A member of the Restore Education staff may contact me or our case management providers and partners to discuss my needs. Partners may include the San Antonio Hope Center, Nxt Level Youth Opportunity Center, the United Way Dual Gen Program, Good Samaritan Center, Family Services, and other professional organizations that provide wrap around support services and financial assistance to our students.
Wrap around services are provided at no cost to me. This could include childcare, bus passes, emergency financial assistance, parenting classes, and more. It’s my choice to participate.
By my signature below, I authorize the release of my name, phone number, email, and needs for services by the Restore staff to the appropriate partner agency.
I understand that some Restore programs require I participate in job placement case management. I also understand that non-participation with job placement case management could result in termination from the program.
This agreement is active while you remain engaged in Restore Education services.
To sign, are you 19 years of age or older OR 18 years old with a HS diploma/GED?*

YesNo
Student's Signature (Your signature MUST match a closely as possible your State ID or DL)

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Participants who are 16 through 18 years of age must have written parent/guardian permission to participate in the program. Parents/guardians, by signing below, you are verifying that information on this enrollment form is correct, giving your child permission to be part of our Adult Education program, and acknowledging release of information.
Parent's Signature (Your signature MUST match a closely as possible your State ID or DL)

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Upload your Parent or Legal Guardian Government Issued Photo ID or DL

Required for applicants ages 16-18 without a HS diploma or GED.
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If you are not the parent, Upload proof of Guardianship

Required for applicants ages 16-18 without a HS diploma or GED.
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ADULT EDUCATION & LITERACY STUDENT ENROLLMENT FORM 2023-2024

I. Personal Data

Identification Information

Contact Information

Participant Status Upon Program Entry

Equal Opportunity Information

Veteran Information

Employment and Education Information

Migrant and Seasonal Farmworker Characteristics

Additional Program Information

Additional Information

Participant Acknowledgement, Release of Information, and Signature