2022-2023 Registration – Fort Wayne Adult Education

Complete Your 2022-2023 Registration Form

"*" indicates required fields

Student ID

Hidden

Date Submitted:

Updated Application Date:

Name:*

Please carefully type your legal name.

Social Security Number:

We do not require you to provide your social security number, but providing it helps us to track your accomplishments as well as any resources we might be able to provide for you. As always, we keep all of our data secure.

Are you a currently a student at any high school in the state of Indiana?*

Yes

PLEASE NOTE: You will not be able to submit this form if you are currently enrolled in any high school in the state of Indiana.

According to Indiana state policy, students who are currently enrolled in a high school cannot also be enrolled with us at the same time.
If you wish to exit your current school so that you may join our program, click here to download and complete the required exit form., then turn the completed form in to our office.

Address:*

Please upload a favorite photo of yourself so that we can use it for your student ID.

Max. file size: 1 GB.

In which county do you live?*

Are you a US Citizen?*

We accept ALL students, regardless of which citizenship status you choose. Clicking NO will not prevent you from enrolling with us.

Yes

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Veteran Status

Country of Birth:*

Mobile Phone Number:*

We communicate important messages to students via text message. If you do not currently have a mobile phone, please list a mobile phone number of a trusted family member or friend so that you can receive messages.

Home Phone Number:

You can leave this blank if you do not have a home phone number.

Email:*

Enter an email address you can access easily and check frequently. Please make sure that you only use ONE email account, and that the email account belongs only to you, as shared accounts are not allowed.

Date of Birth:*

Age:

You’re underage, please call the FWCS Continuing Ed office (260-467-1060) to schedule a meeting with you, your parent/guardian, and an administrator.

Passcode*

Gender:*

Male

Female

Other

Please list any other legal names you have had in the past.

For example, if you are married and your last name has changed, list your previous last name here. If you have never had a different name, leave it blank.

Ethnicity:*

NOTE: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race, refers to Hispanic ethnicity. Please select the option below that describes your ethnicity.

Race:*

Please select all that apply.

African American

Asian

American Indian

Pacific Islander

White

None of these describe me.

Name of Emergency Contact:*

Who can we contact if we cannot reach you?

First Last

Emergency Contact's Phone Number:*

Employment Information

Employment Status: (Choose the one that best describes you.)*

I am NOT IN THE LABOR FORCE, as I am not working, not able to work, or not looking for a job.

I am able to work but am currently NOT EMPLOYED.

I have been UNEMPLOYED FOR MORE THAN 26 WEEKS.

I am EMPLOYED.

I am EMPLOYED, BUT MY JOB IS BEING TERMINATED.

Employer/Company Name:*

Date of Hire:*

If you do not remember the exact date you were hired, you can choose the date that is your best estimate of when you were hired.

Educational Information

Educational Status:*

Please check the highest level of education you have completed.

Last Grade Completed:*

Please choose the highest grade level (1-12) that you completed. *If you have completed education beyond high school, just select “12.”

Last School Attended:*

Please type the name of the last school you attended.

Where did you complete most of your education so far?*

U.S.-based schools

Non-U.S.-based schools

School Attendance Status at Entry:*

Select the option that BEST describes your current school situation:

In-school: Grades k-12

In-school: Alternative School

In-school: Postsecondary (beyond 12th grade)

I am not already attending school – I am 18 or older – I did NOT finish high school.

I am not already attending school – I am less than 18 years old – I did NOT finish high school.

I am not already attending school, and I already earned a High School Diploma, a GED, or an HSE Diploma.

Household Information

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Current Enrollment Type:*

For which reason are you interested in coming to school?

Resident Institution:*

Please select the option that describes your residential situation.

Correctional Facility

Community Corr. Facility

Medical/Group/Nursing Home

None of these apply to me.

How did you hear about our program?*

Demographics

For each of the questions below, select the answer that best describes you.

I have physical, mental, or learning impairments.

Yes

I live in an urban area (inside city).*

Yes

I live in a rural area (outside city).*

Yes

I currently receive public assistance.*

Examples of public assistance include TANF or SNAP (food stamps).

Yes

I consider myself to have low income, which means I do not have enough money to pay my bills.*

Yes

I am a displaced homemaker, which means I used to be a homemaker, but due to a change in financial circumstance, I must now enter the workforce.*

Yes

I am a single parent.*

Yes

I am a dislocated worker – I was laid off from my job due to the company moving away.*

Yes

I am a dependent, or I have dependent(s).*

Yes

I am/was a Foster Care Youth.*

Yes

I am considered homeless, which means that I do not have a permanent, regular nighttime residence (other than a vehicle, a shelter, or staying on someone’s couch).*

Yes

I speak a language other than English at home.*

Yes

What is the language you first learned as a child?*

Hidden

Annual Family Income (yearly income before taxes):*

We are asking this information for the purpose of finding resources for you. We accept all students, regardless of family income.

Hidden

Household Size: How many people live in your household, including yourself?*

Are you a dependent yourself, or do you claim to have dependent(s) in your household?*

A YES response means that either someone claims you as a dependent OR you claim to have dependent(s) yourself.

Yes

Household Size: How many people live in your household, including yourself?*

We accept ALL students, regardless of family income.

Annual Family Income (How much is your family income in one year?*

We have many resources to help our students overcome barriers that might make it difficult to come to school. Please select any of the issues listed below that apply to you, as we may be able to help! Select all that apply.*

I am a Migrant/Seasonal Farm Worker.*

Please select the option that best describes you:

Yes

I am an Active Military member.*

Please select the option that best describes you:

Yes

I am the spouse of an active military member.

Are you involved in a Vocational Rehabilitation agency?*

Please select the option that best describes you.

I utilize Wagner Peyser Employment services, a federally-funded program that connects employers with job seekers.*

Yes

Unknown

Ex-Offender:*

Have you ever been convicted of a crime?

Yes

Unknown

Cultural Barriers to Employment:*

Do you have any cultural barriers that affect your job opportunities?

Yes

Unknown

Release of Information

I am enrolling in an Adult Basic Education (ABE) program. This ABE program works with the following programs and agencies to help students improve their skills and earn better jobs:
• Other state-funded adult education programs
• WorkOne offices and job training programs
• Public and private colleges
• State executive offices, departments, and agencies, including the Indiana Department of Workforce Development (IDWD), Division of Adult Education and the Indiana Department of Education.

By signing below, I understand and agree to the following:
• The information on my intake form is correct.
• DWD use of directory information (name, address, birth, and social security number) to match test score records, wage information, and college/training program enrollment records that assist the state to evaluate and improve its programs and to report results to the federal and state government.
• The sharing of information between the agencies and programs listed above. This information may include my name, enrollment information, education/career goals, test scores, HiSET test account information and scores, and employment history. The information will be kept strictly confidential and will be used for program administration, research, and evaluation purposes.

I agree to the Release of Information described above.*

Yes

Photo Release

We love to celebrate success with our students, and we often do that through pictures, articles, slideshows, and other fun media. In order for you to participate in that, we will need permission to use your photo.

I grant Fort Wayne Community Schools Adult Education, its representatives and employees the right to take and/or use provided photographs of me in connection with documents and promotional materials published by the same. I authorize Fort Wayne Community Schools Adult Education, its representatives and employees, to use and publish the same in print and/or electronically. I agree that Fort Wayne Community Schools Adult Education may use such photographs of me with or without my name for purposes including training and instruction manuals, promotional materials, and electronic documents.

Student Photo Release:*

I agree to the above photo release statement.

I do not agree to the above photo release statement.

Student Contract/Code of Conduct

Please review our Student Contract, which can be viewed and printed by clicking the link below. The link will open in a new tab, so please make sure to come back to this tab to finish signing and submitting this form after you review the student contract.

Click here to download and print the Fort Wayne Community Schools student contract.

Student Contract Agreement*

I have read, and I agree to abide by, the rules in the Fort Wayne Community Schools Adult Education student contract, which can be viewed and printed by clicking the link above.

Yes

Electronic Signature

Typing your name in the fields below will constitute your electronic signature(s) for the above provided information. Please verify that all information is accurate before you sign. Applicants who are under 18 years of age will require a parent/guardian signature as well.

Signature*

Please type your full name, as this will serve as your electronic signature. This signature acknowledges that the information provided in this form is correct.

Parent/Guardian Signature*

Parent/Guardian, please type your full name, as this will serve as your electronic signature. This signature acknowledges that the information provided in this form is correct.

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Program Year

20202021

20212022

20222023

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Program ID

[ABE_36] ABE Program Ft Wayne