Adult Education Pre-Registration Form

Choose a Program *

ELA (ESL)

HSE (GED)

You must watch the following video before completing this form:

Did you watch the Adult Education Information video on the website? *

Yes

Your Identity

Student ID Number
Enter X-Number if known. If this is your first time at Waubonsee
or you do not know your X-Number, please leave this blank.

Legal Name: Last *

Legal Name: First *

Legal Name: Middle

Preferred/Chosen Name

Legal Sex *

Male

Female

Birth Date:

Month *

Day *

Year *

Ethnic Background

In what country were you born? *

Is English your native language? *

Yes

No

What is your Native Language? *

Ethnicity *

Contact Information

Address *

Apartment or Unit Number

City *

State *

Zip Code *

Email *

Phone *

Phone Type *

Home

Cell

Who can we contact in case of an emergency? *

	Name	Phone number	Relationship
Contact	Name	Phone number	Relationship

Education

Is this your first time at Waubonsee? *

Yes

No

When were you here? *

What type of school did you attend previously? *

U.S. School

Non-U.S. School

No formal education or school

Please mark the highest level of education you completed. *

Highest grade completed *

What is the name of the last school you attended? *

Do you have a U.S. High School Equivalency (GED)? *

Yes

No

Do you have a U.S. High School Equivalency (GED)? *

Yes

No

Do you have a U.S. High School Diploma? *

Yes

No

Do you have a U.S. High School Diploma? *

Yes

No

Miscellaneous

Do you have a disability? *

No

Yes, as defined by the ADA

I prefer not to say

Please identify your disability

Where do you live? *

A rural area (in the country)

An urban area (city) with high unemployment

Neither (suburban area)

Do you currently have a job? *

I am employed

I am employed, but received notice of termination or military separation

I am unemployed and looking for work

I am not in Labor Force and not looking for work

Average hours per week *

Do you receive Public Assistance? *

No

Yes

Please identify your Case #

Agreement & Signature

Consent to Release Testing Results *

I give my consent to Waubonsee Community College to obtain the results of my High School Equivalency (HSE) testing. I understand that all information obtained by Waubonsee Adult Education will be maintained in accordance with the Family Educational Rights and Privacy Act and will only be used for the following purposes:

Information regarding the annual recognition ceremony;
Determining eligibility for available scholarships and notifying me of the same;
Tracking student progress through the HSE program; and
Responding to all mandated state reporting requirements.

By signing this form, I acknowledge that Waubonsee Adult Education may obtain my official HSE test results and give permission for all such results to be provided to Waubonsee Adult Education.

In lieu of a signature, please type your name as an agreement that the information you provided is correct. *

White	Black/African American
Hispanic/Latino	Asian
American Indian/Alaska Native	Prefer not to answer
Other/Not listed	Native Hawaiian or Pacific Islander

Grade (fill in the blank)	High School Diploma
GED or High School Equivalency	Some university, no degree
University/Professional degree