• WIOA Title II Arizona Adult Education Participant Eligibility for Services

  • A.R.S. §15-232(B) states that "The Department of Education shall provide classes under this section only to adults who are citizens or legal residents of the United States or are otherwise lawfully present in the United States. This subsection shall be enforced without regard to race, religion, gender, ethnicity, or national origin.”

     

  • Please mark only one eligibility option. If you are not sure about your eligibility status for services, please consult program staff.*

  • I affirm under penalty of perjury that I am a citizen of the United States, a legal resident of the United States, or otherwise lawfully present in the United States. Should my status change, I understand that it is my responsibility to withdraw from classes until I am again lawfully present in the United States.

  • (Participant legal name as it appears on the presented identification.)

  • Contact Information

    Please include at least one phone number.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Contact Preference
  • Format: (000) 000-0000.

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    Form v 4.0 — 2026-06-25

  • Registration Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have a valid Social Security Number?*

  • Please enter your Social Security Number in the fields below.

    (e.g., 123 - 45 - 6789)

     

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender/Sex*
  • Are you currently under the age of 18 (16 or 17 years old)? *
  • Residence Area (optional)
  • Mailing Preference (optional)

  • Tribal Affiliation

  • Are you affiliated with a federally recognized American Indian Tribe, Alaska Native Village, or a Canadian First Nation?*

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    Form v 4.0 — 2026-06-25

  • Ethnicity/Race

  • Are you Hispanic/Latino?*

  • * (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

  • Please choose one or more races below. *

  • Education and Employment

  • Check the highest grade or education level completed. If education was not based in the U.S., please estimate. *
  • Location of highest grade or education level completed: *
  • Check current employment status. *
  • Per*

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    Form v 4.0 — 2026-06-25

  • Do any of the following situations apply?

  • The participant indicates that he or she has any disability, defined as a physical or mental impairment that substantially limits one or more of the person's major life activities, as defined under the Americans with Disabilities Act of 1990.

  • Individual with Disabilities, including Learning Disability *

  • The participant has been providing unpaid services to family members in the home and

    1. has been dependent on the income of another family member but is no longer supported by that income;
    2. is the dependent spouse of a member of the armed forces on active duty whose family income is significantly reduced because of
      1. a deployment or a call or order to active duty pursuant to a provision of law,
      2. a permanent change of station, or
      3. the service-connected death or disability of the member; and
    3. is unemployed or underemployed and is experiencing difficulty in obtaining or upgrading employment.
  • Displaced Homemaker *

  • The participant

    1. receives, or in the 6 months prior to application to the program has received, or is a member of a family that is receiving in the past 6 months assistance through the Supplemental Nutrition Assistance Program (SNAP), the TANF program, the Supplemental Security Income (SSI) program, or State or local income-based public assistance;
    2. is in a family with total family income that does not exceed the higher of the poverty line or 70% of the lower living standard income level;
    3. is a youth who receives, or is eligible to receive, a free or reduced-price lunch;
    4. is a foster child on behalf of whom State or local government payments are made;
    5. is a participant with a disability whose own income is the poverty line but who is a member of a family whose income does not meet this requirement;
    6. is a homeless participant or homeless child or youth or runaway youth; or
    7. is a youth living in a high-poverty area.
  • Low-Income *

  • The participant is a person who either

    1. has been subject to any stage of the criminal justice process for committing a status offense or delinquent act, or
    2. requires assistance in overcoming barriers to employment resulting from a record of arrest or conviction.
  • Ex-Offender *

  • The participant is within 2 years of exhausting lifetime eligibility under Part A of Title IV of the Social Security Act (42 U.S.C. 601 et seq.), regardless of whether he or she is receiving these benefits at program entry.

  • Exhausting Temporary Assistance for Needy Families (TANF) within Two Years *

  • The participant is a person currently in foster care or out of the foster care system.

  • Youth in Foster Care or Who is No Longer in the System*

  • The participant lacks a fixed, regular, and adequate nighttime residence; has a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings; is a migratory child who in the preceding 36 months was required to move from one school district to another due to changes in the parent’s or parent’s spouse’s seasonal employment in agriculture, dairy, or fishing work; or is under 18 years of age and absents himself or herself from home or place of legal residence without the permission of his or her family (i.e., runaway youth). However, a participant sleeping in temporary accommodation while away from home should not be recorded as homeless.

  • Homeless or Runaway Youth*

  • The participant has been unemployed for 27 or more consecutive weeks.

  • Long-term Unemployed*

  • The participant is a low-income individual who for 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 faces multiple barriers to economic self-sufficiency.

  • Migrant or Seasonal Farmworker*

  • The participant is a single, separated, divorced, or widowed individual who has primary responsibility for one or more dependent children under age 18 (including single pregnant women).

  • Single Parent or Guardian*

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    Form v 4.0 — 2026-06-25

  • Are you currently receiving Public Assistance?*
  • Check all that apply: *
  • Are you a dislocated worker? *

  • * (An individual who lost their job through no fault of their own and is unlikely to return to the previous industry or occupation usually due to outdated skills, job loss, mass layoff, military move, or other economic conditions.)

  • Are you currently in the military?*
  • Have you ever served in active duty, reserves, or National Guard of the U.S. Armed Forces?*
  • How did you Hear about Our Program? *
  • Which of the following do you have at home so we can contact you and/or connect you to services? (check all that apply)

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    Form v 4.0 — 2026-06-25

  • Validity of Information

    By signing below, I confirm that the information I have provided in this declaration and document is true and correct and that any document(s) I present are genuine. I understand that false information or documents related to this declaration may subject me to expulsion from the program and/or other legal actions.

  • Family Educational Rights and Privacy Act Release

    To attend adult education programs funded through the Arizona Department of Education (ADE), the participant must allow his or her information to be entered into and shared with designated adult education data systems, including the state-mandated testing platform, and all Workforce Innovation and Opportunity Act (WIOA) Core Partners’ data systems. Your information will be shared with your Title II adult education program, instructors, and the Arizona Department of Education. This information is used for program operations, student instruction, employment opportunities, and to compile federal and state reports of non-identifying aggregate student data.

  • My signature below verifies my acceptance that I have reviewed and understand the policies associated with enrolling in courses at CCC. I understand Coconino Community College may request documentation from me to confirm the information I have provided.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: