Adult Education Program Student Registration Form

Completion of this form is required for all adult learners in all programs. Required data fields are indicated with an asterisk (* Please print legibly. All signatures should be in ink.

*Pre-test date, form/level, score:

*Instruction Mode: In person

Today's Date*

Date

Orientation Date

Date

Social Security Number

SSN

Date of Birth*

Date

Age

First Name*

Middle Name

Last Name*

Suffix

Preferred Name

*Email Address*

example@example.com

Address*

Apt or Unit Number

City*

State

Zip

*County*

Cell Number*

Area CodePhone Number

Other Phone

Area CodePhone Number

First Name*

First

Last Name*

Last

Phone*

Area CodePhone Number

Relationship*

Hispanic/Latina/Latino*

No, not Hispanic/Latina/LatinoYes, Hispanic/Latina/Latino

Race*

Preferred Sex*

FemaleMale

Preferred Pronouns

*Highest school grade you completed? (select one)*

Highest degree level you completed? (select one)*

Was your highest educational level completed in the United States or at a U.S.-based school?*

YesNo

Have you enrolled in Adult Education before?*

NoYes

Yes. Which Program?

How did you hear about us?

Suffix

*What is your work status? (select one)*

TANF (Temporary Assistance for Needy Families)*

YesNo

Have you received TANF for more than 2 years in total?*

YesNo

SNAP (Supplemental Nutrition Assistance Program) “Food Stamps*

YesNo

SSI (Supplemental Security Income)*

YesNo

State or Local income-based public assistance*

YesNo

Choose all that apply

I have low incomeI am a former homemaker who is having trouble finding a job or a better job.I am a single parent. I am unmarried or separated from my spouse and have primary responsibility for one or more dependent children under the age of 18 or I am a single, pregnant womanI am homeless. I live in a motel, hotel, campground, transitional housing, or with another person because I lost my house or apartment.I have a criminal record that makes it hard to find a job. (Do not select if you are currently incarcerated.)I am in the foster care system (or I used to be) and I am less than 24 years old.I am a farmworker.(If yes, select a subcategory)

I am a farmworker. (If yes, select a subcategory)

I am a seasonal farmworker who has worked the last 12 months in agricultural or fish farming labor.I am a seasonal farmworker with no permanent residence (migrant).I am a dependent of a farmworker.

Are you an individual with a physical and/or learning disability?*

YesNoDo not wish to disclose

*Do you request special accommodation(s) based upon your physical and/or learning disability?

YesNo

If the class you attend is associated with a correctional facility, please provide your GDC ID#

Language spoken at home

Country of Birth*

By signing this, I agree to all of the statements in the Terms and Conditions provided to me. I agree and verify that the information provided is true and correct.

Student’s Signature*

*Date*

Date

Technical College System of Georgia, Office of Adult Education, Student Registration Form, Updated June 9, 2023, Effective July 1, 2023

I agree that the information submitted is accurate and can be used for contact and registration purposes. I give the adult education provider permission to release my student information for specific reasons allowed under the Family Educational Rights and Privacy Act (20 U.S.C. § 1232g; 34 CFR Part 99), such as program evaluation purposes. I understand that it is my responsibility to notify TCSG and its grant-funded adult education providers if I choose not to release my student information for specific reasons allowed under the Family Educational Rights and Privacy Act by visiting www.GeorgiaOpportunities.com or emailing oaereporting@tcsg.edu. I understand that pursuant to O.C.G.A. 16-10-20, it is a felony to make a false statement on any document. In addition, making a false statement may result in dismissal from the college. If and when applicable, I give the GED® and HiSET® testing publishers permission to release my test score information to my adult education provider for instructional and evaluation purposes. I understand that it is my responsibility to notify TCSG and its grant-funded providers if I choose not to release my high school equivalency test scores for instructional and evaluation purposes or choose to rescind my previously granted permission by visiting www.GeorgiaOpportunities.com or emailing oaereporting@tcsg.edu. I understand that the Technical College System of Georgia (TCSG) and its grant-funded adult education providers are not liable for any emergency medical attention provided nor for charges incurred from such. I give TCSG and its grant-funded adult education providers permission to contact me at the telephone numbers and email addresses I have provided via any means, including text message or voice. TCSG and its grant-funded adult education providers will not be liable for any data rates that may apply. All materials submitted for application become the property of TCSG and its grant-funded adult education providers and will not be returned to the applicant. I understand that I have the right to inspect and review my education records to the extent allowable under the federal Family Educational Rights and Privacy Act (“FERPA”, 20 U.S.C. § 1232g, 34 C.F.R. Part 99 I understand that my name, quotations, and photographic likeness may be used in all forms of media for advertising, trade, and any other lawful purpose on behalf of TCSG and its grant-funded adult education providers and that I will not receive now or in the future, any compensation for this usage. I also understand that my name, quotations, and photographic likeness may be posted on TCSG and its grant-funded adult education providers’ websites and/or its official social media sites, and can be downloaded by any computer user on or off campus. Therefore, I agree to indemnify and hold harmless the State of Georgia, Ogeechee Technical College, the Board of TCSG, TCSG, their members individually, and their officers, agents, and employees, from any and all claims of any kind, whether foreseeable or not, arising from such use of my likeness. I understand that, as a student aged 18 or older, it is my responsibility to notify the TCSG and its grant-funded adult education providers, Ogeechee Technical College at One Joe Kennedy Blvd. in Statesboro, GA; if I refuse to have my name, quotations, or photographic likeness used for the provider’s unlimited purposes. In addition, all students under the age of 18 must have parent or guardian permission for his or her name, quotations, or photographic likeness to be used by the college. The Technical College System of Georgia and its grant-funded adult education providers do not discriminate on the basis of race, color, creed, national or ethnic origin, sex, religion, disability, age, political affiliation or belief, genetic information, disabled veteran, veteran of the Vietnam Era, spouse of military member or citizenship status (except in those special circumstances permitted or mandated by law

Technical College System of Georgia, Office of Adult Education, Student Registration Form, Updated June 9, 2023, Effective July 1, 2023

Adult Education Program Student Registration Form

*Entry Educational Functioning Level:

*Site/Class:

Institution 1:

Institution 2:

EMERGENCY CONTACT INFORMATION

STUDENT DATA

STUDENT STATUS and SPECIAL POPULATIONS

*Have you (or someone in your household) received any of the following in the last six months?

*Do any of the following statements apply to you?

SIGNATURES

Terms and Conditions