Bristol Adult Education ESOL Student Information (Intake) Form

Bristol Adult Education ESOL Student Information (Intake) Form
Today's Date

MonthDayYear
Month - Day - Year
Do you have a Social Security Number?

YesNo
If you have a Social Security Number, please enter the number below:
Last Name*
Enter the LAST NAME(S) or "surname" listed on your official identification card.
First Name*
Enter the FIRST NAME listed on your official identification card.
Middle Name(s)
Enter any name(s) following the FIRST NAME and before the LAST NAME(S) listed on your official identification card.
Preferred Name
Enter the name you are called every day or how you would like to be addressed as a student.
Suffix (if you are a "Jr." or a "Sr.")
Birthdate*

MonthDayYear
Please enter month-day-year that you were born.
Sex*
Gender Identity
Pronouns
Do you identify as Hispanic/Latino/Latina/Latine/Latinx?*
Race: What US racial category or categories do you identify with? Select one or more.*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
Country of Birth*
Primary Language*
What is the HIGHEST level of education you have completed to date? Select one. *
WHERE did you complete your HIGHEST level of education? Select one. *
Have you been enrolled in the MA public education system? Select one. *
Employment Status*
Barriers to Employment: Choose English Language Learner and others that apply.*

English Language LearnerCultural BarriersDisabilityDisplaced HomemakerLow IncomeEx OffenderExhausting TANF Within Two YearsFoster Care YouthHomeless/UnhousedLong Term UnemployedLow Literacy LevelsMigrant FarmworkerSeasonal FarmworkerSingle Parent or Guardian
Street Address*
Apt/Unit (if applicable)
City/Town*
Zip Code*
Which of the following do you have at home? (Check all that apply.)*

Computer with CameraComputer without CameraWebcamHeadset with MicrophoneMobile/Cellular PhoneHome PhoneInternet AccessPrinterScanner
Mobile Number*
US-based Mobile Phone Number: (###) ###-####
Other Phone Number
US-based Phone Number: (###) ###-####
Email*

Confirmation Emailexample@example.com
Emergency Contact Name*
Emergency Contact Phone Number*
US-based Phone Number: (###) ###-####
Emergency Contact Relation*
Would you like to disclose a disability?*
If you answered "Yes" above, please provide more information about your disability below:
Do you receive Public Assistance? (Check all that apply.)

EAEDCMassHealthSNAP (EBT/Food Stamps)SSITAFDC (TANF)WICOther Benefit
How did you hear about the Bristol Adult Education ESOL Program? (Check all that apply.)*

Career CenterAnother StudentFriend/Family MemberMy Child's SchoolDTAA Service Provider (Examples: counselor, doctor, dentist, mail carrier)Other
Free ESOL Lottery Group Selection: Class Time*

9am - 1pm6 - 8:30pm
Free ESOL Morning Lottery Group: Class Location*
Bristol ESOL morning classes are based in Taunton.
Free ESOL Evening Lottery Group: Class Location*
Bristol ESOL evening classes are based in Fall River and Taunton.
Adult and Community Learning Services
Release of Information Acknowledgment

Dear Student:

The Massachusetts Department of Elementary and Secondary Education (DESE) funds the Bristol Adult Education ESOL and others like it. In order to continue to support these programs, DESE must report information about students, including student outcomes, to the federal government.

After students leave their program, DESE collects information about their outcomes by matching their personal information with Department of Unemployment Assistance employment data, with GED and HiSET high school equivalency (HSE) test results, and with National Student Clearing House and Department of Higher Education postsecondary enrollment records. DESE combines the data sets and reports them to the federal government.

By signing this required Release of Information form electronically, you authorize DESE to share your employment data, test results, and postsecondary enrollment information with the Bristol Adult Education ESOL program, so it can understand how well it is helping students. DESE and your Adult Education program will not disclose this confidential information under any other circumstances unless required to do so by law.

Thank you.
Signature*

Clear
Bristol Adult Education Minimum Participation Requirements

Bristol Adult Education ESOL classes are funded by the Massachusetts Department of Elementary and Secondary (MA DESE). Bristol Adult Education ESOL students must meet minimum participation requirements to maintain eligibility for free classes. Review and acknowledge the program requirements below to proceed. Email ESOL@bristolcc.edu if you have questions about Bristol Adult Education ESOL Program Minimum Participation Requirements.
Click to acknowledge the following program participation requirement:

I understand that I must maintain at least 75% participation rate (class attendance and homework completion) to remain eligible for free Bristol ESOL classes.
Click to acknowledge the following program participation requirement:

I understand that I am expected to arrive before the start of class and return from breaks on time.
Click to acknowledge the following program participation requirement:

I understand that I am expected to store my mobile phone out of sight and on “silent-mode” unless use is specifically requested by the teacher.
Click to acknowledge the following program participation requirement:

I am understand I am expected to show courtesy to my peers and teacher by listening when others are speaking.
Click to acknowledge the following program participation requirement:

I understand that I am expected to practice respectful listening and refrain from conversation while instructors and other students are speaking in class.
Click to acknowledge the following program participation requirement:

I understand that if I complete class work before my peers, I am expected to read quietly or complete additional practice in Burlington English until the teacher resumes the lesson.
Click to acknowledge the following program participation requirement:

I understand that I will be dismissed from free Bristol ESOL classes if I do not appear in person for assessment testing when requested and must reschedule a missed assessment test by email at ESOL@bristolcc.edu within 7 days if I miss my scheduled appointment.
Click to acknowledge the following program participation requirement:

I understand that I must be able to send email to ESOL@bristolcc.edu to participate in free Bristol ESOL classes. I also understand that all official notifications will be sent to me by email.
Click to acknowledge the following program participation requirement:

I understand that the maximum length of stay in any Bristol ESOL Class Level is 4 semesters (2 academic years).
Click to acknowledge the following program participation requirement:*

I understand that Chromebooks and other devices provided on loan from the Bristol Community College Library must be returned at the end of the semester and that I am responsible for any loss or damage to Bristol Community College Library property.
Click to acknowledge the following program participation requirement:

I understand all Bristol Adult Education online/remote classes have on-campus requirements for participation including orientation, textbook pick-up, and English testing 2 -3 times each semester.
Signature

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Bristol Adult Education ESOL Student Information (Intake) Form

Bristol Adult Education Minimum Participation Requirements