Adult Ed 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

Contact Information

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 *

Email *

Phone *

Phone Type *

Home

Cell

Address *

Apartment or Unit Number

City *

State *

Zip Code *

Who can we contact in case of an emergency? *

	Name	Phone number	Relationship
Contact	Name	Phone number	Relationship

Ethnicity and Education

Is English your native language? *

Yes

What is your Native Language? *

In what country were you born? *

Is this your first time at Waubonsee? *

Yes

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. *

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

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

Yes

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

Yes

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

Yes

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

Yes

Miscellaneous

Do you have a disability? *

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 receive Public Assistance? *

Yes

Please identify your Case #

Agreement & Signature

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

Waubonsee Community College does not discriminate based on any characteristic protected by law in its programs and activities.

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