FY23 RIRAL Intake / Registration Form

Instructor
Program*

English classes (ESOL)Adult Education (GED, NEDP, reading, writing, and math)EQUUS
Class Location*

WoonsocketProvidenceEast Providence

Welcome to RIRAL!

Please click on each of the red sections below and answer the questions.

* indicates that a response is required

If you have any questions, please let us know.

Program Information
Class Preference (check all that apply)*

in-persononlinenot sure
I am interested in (check all that apply)*

day classesevening classes

Contact Information
Personal Email Address
RIRAL Email Address
example@student.riral.org
Cell Phone Number*
Home Phone Number
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Information

Name

Relationship

Phone Number

Zip Code

Employment Status
Employment Status*

I am employedI am unemployedI am not in the labor force (not employed and not seeking employment)I am employed and have received a notice of pending or actual layoff from a job or military
Please check ALL that describe you:

I am not a permanent resident but I have work authorizationI am a dislocated workerI am a seasonal farmworkerI am a migrant farmworkerI have been unemployed for 27 weeks or more

Background Information
Check one that describes you:

U.S. CitizenBorn in Puerto Rico or Virgin IslandsBorn abroad of U.S. parentsForeign born / not a citizenForeign born / naturalized citizenAsylumRefugee
If foreign born, date of arrival in the US:

MonthDayYear
Place of Origin
Where are you from?
Country not listed:
Country of origin if not listed above
Native Language
What was the first language you learned?
Other Language(s)

Technology Access
What technology do you have at home? Please select all that apply*

Laptop / ChromebookWeb CameraSmart PhoneMicrophone / SpeakersMouseWi Fi / Internet

Accommodations
YOUR RIGHT TO ASK FOR ACCOMMODATIONS

Any details you share about a disability or learning difference will be kept confidential.
Optional: Do you have any physical limitations or health concerns that your teacher should know about so that you can learn more easily in class? If yes, please describe:
Optional: Do you have learning disabilities or difficulties? If yes, please describe:
Optional: I have a diagnosed disability. I know what accommodations I will need to participate in class. If true, please describe:
I would like to get more information about possible accommodations.

YesOther

Selective Service
US Selective Service Notification

Almost all male US citizens and male immigrants, who are 18 through 25, are required to register with Selective Service. For more information on who needs to register, please click here:

Registering for the Selective Service does not automatically induct you into the military. Click the link above for more information.

A young man who fails to register with Selective Service before his 26th birthday may be ineligible for opportunities that may be important to his future. He must register to be eligible for federal student financial aid, state-funded student financial aid in many states, most federal employment, some state employment, security clearance for contractors, job training under the Workforce Innovation and Opportunity Act, and U.S. Citizenship for immigrant men.

If a man fails to register, he may find that some doors are permanently closed. Failing to register or comply with the Military Selective Service Act is also a felony punishable by a fine of up to $250,000 or a prison term of up to five years, or a combination of both. A person who knowingly counsels, aids or abets another to fail to comply with the act is subject to the same penalties.

Registration can be checked on the Selective Service System web page.
Selective Service:*

I am a man between the ages of 18-25 and I have been made aware of my obligation to register with the US Selective Service and of how to register.I am NOT a man between the ages of 18-25.

Permissions & Policies
I give permission to the Rhode Island Department of Education to use the information collected in the Literacy, Adult, and Community Education System (LACES) for data matching, research, and evaluation as long as my individual information is never made public.
Yes, I give permission for my data to be used anonymously.No, I do not give permission.
I give permission for my educational record to be released to other institutions for educational purposes. (FERPA)
I give permission for my educational record to be released to other institutions for educational purposes. (FERPA)*

Yes, I give permission for my academic record to be released.No, I do not give permission.
RIRAL does not discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, height, weight, or veteran status in employment, educational programs and activities, and admissions. Additionally, the lack of English language skills will not be a barrier to admissions.
I understand the above policy of non-discrimination.
The RIRAL Student Handbook can be found at www.riral.org/student-handbook. Students may request a printed copy.

The handbook covers topics such as: Attendance Policy, Student Rights & Responsibilities, Cell Phone Policy, and Code of Conduct.
I understand that I am responsible for the information contained in the RIRAL Student Handbook

Sign & Submit
Electronic Signature*
Please type your full legal name.
Should be Empty:

Welcome to RIRAL!

YOUR RIGHT TO ASK FOR ACCOMMODATIONS

US Selective Service Notification