ELL/GED Registration
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ELL/GED Registration Form
If you need to contact our Student Services Department, the numbers are 239-377-4556 or 239-377-9941.
1.
Program:
*
Program:
*
ELL- English Language Learners
GED
2.
Preferred Time:
*
Preferred Time:
*
ELL Daytime (Monday-Friday)
ELL Evening (Monday-Thursday)
GED Daytime (Monday-Friday)
GED Evening (Monday-Thursday)
3.
Name:
*
(As it appears on Government Issued ID)
First:
Last:
4.
Phone:
*
(000)000-0000
5.
Email:
*
6.
Address:
*
Street Address:
Address Line 2:
City:
State:
Zip:
Country:
7.
Social Security #:
*
8.
Date of Birth:
*
mm/dd/yyyy
9.
Emergency Contact:
*
10.
Emergency Contact Phone:
*
11.
Gender:
*
--Please Select--
Female
Male
Prefer not to answer
12.
City of Birth:
*
13.
Country of Birth:
*
14.
Ethnicity:
*
Ethnicity:
*
Latino or Hispanic Origin
Non-Latino/Hispanic Origin
15.
Primary Language:
*
Primary Language:
*
English
Spanish
Creole
Mam
Other, please specify
16.
Race
*
(Select all that apply)
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
17.
Highest School Grade Completed:
*
(Select One)
--Please Select--
No school grades completed
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
11th
12th
Completed twelfth grade, but did not attain a diploma or equivalency
Earned a high school diploma
Earned a high school equivalency
Completed some college, but did not earn a certificate or degree
Earned a Career Certificate
Earned and Associate of Applied Sciences degree
Earned and Associate of Science degree
Earned and Associate of Arts degree
Earned and Bachelor's degree
Attained beyond a Bachelor's degree
18.
Where this level was achieved:
*
Where this level was achieved:
*
U.S. based school
Not a U.S. based school
19.
Employment Status:
*
(Select One- To be completed upon entry for each term/semester)
--Please Select--
Employed
Employed but with Notice of Termination or in transition out of military service
Not Employed (looking and eligible for employment)
Not in the Workforce
20.
Citizenship Status:
*
(Select One- To be completed upon entry for each term/semester)
--Please Select--
Non-Resident Alien
Permanent Resident Alien
U.S. Citizen
Unknown
21.
Background:
*
(Select all that apply- To be completed upon entry for each term/semester)
Youth in Foster Care (including aged-out)
Single Parent
Single Pregnant Woman
Perceived employment barriers
Previously or currently subject to any stage of criminal justice process
Low-income individual (or their dependent) employed primarily in farming currently unemployed or finding difficulty obtaining work for 12 months out of the last two years
Migrant or seasonal farmworker (or their dependent)
Homeless without a fixed, regular nighttime residence
Homeless but staying in non-traditional housing (ex: park, abandoned building, or bus station)
Child of migrants who have changed school districts in the last 3 years due to parents’ seasonal employment
Previously unemployed or underemployed while caring for home and family(unpaid)
Previously supported by public assistance or family, and now unemployed or underemployed
Parent of a child within two years of no longer receiving TANF (formerly AFDC)
I am currently eligible to receive Temporary Assistance for Needy Families (TANF)
As of today I have been unemployed for 27 weeks or more
As of today, I qualify as having low income based on the one or more of the following: ∙ I or immediate family receive benefits under Supplemental Nutritional Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Supplemental Security
Unemployed dependent spouse of a member of the Armed Forces on active duty or is deceased or disabled as a result of military service
None apply to me
22.
Military Duty:
*
--Please Select--
No Military History
Active Duty Personnel
Eligible Dependent
Active National Guard
Active Reserves
Veteran prior to 9/11/2001
Veteran on or after 9/11/2001
The school system provides services for persons with disabilities. If you need assistance in the course of your studies, please notify a school or college administrator. Section 119.071 (5)(a)2.-4., Florida Statutes requires agencies to notify individuals of the purpose(s) that require the collection of Social Security numbers. The Adult Education Department of The School District of Collier County collects student’s Social Security numbers for the following purposes: *Social Security numbers are used by the Florida Department of Education as a standardized identification number for the required reporting of yearly learning information, annual deliverables, and other required annual reports and data transmittals. I hereby certify that the information I have given on this registration is true and complete. I understand that a false statement will be subject to penalties pursuant to 837.06, Florida Statues. I understand there are NO REFUNDS available. I understand that I will be dropped from the program if I accumulate six (6) consecutive absences.
23.
Student Signature:
*
By typing your name, as an electronic signature, you agree that the information you provided is true.
24.
Date:
*
mm/dd/yyyy
25.
Parent/Guardian:
(If under 18)