Charlestown Adult Education
FY22/23 Adult Education Student Intake Form
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Intake Date (Today's Date): *
Social Security Number: (optional)
(If willing to provide, please provide last 4 digits; you will be contacted directly for the full number)
Last Name *
First Name: *
Middle Name:
Example: Jr., Sr., The 3rd, etc.
Service: *
(Check the ONE that BEST APPLIES.)
Secondary Service: *
Date of Birth *
If the applicant is under 18 years of age, we will require an official letter of withdrawal. The applicant may still apply and be enrolled, but will not be able to take official HiSET tests until this document is provided or the applicant becomes 18.
Gender *
Are you Hispanic/Latino? *
What is your race? *
(Check ALL that apply:)
Country of Birth *
Were you ever enrolled in MA public education (K12, Adult Education, Community College)? *
Highest educational level completed on entry: *
Where did you receive your highest level of education? *
Employment Status at Program Entry: *
Barriers to Employment: *
(Check ALL that apply. Must select at least either “English Language Learner” (ESOL) or “Low Literacy Levels” (HiSET))
Students with Disabilities
This Adult Education program does not discriminate on the basis of disabilities. Students/Applicants may disclose any disabilities they have but are NOT required to do so. If a student/applicant opts to disclose a disability, they may be entitled to accommodations. Please answer the following questions:
Do you understand that you are NOT required to disclose any disability you may have? Please answer with "Yes" or "No". *
Do you have any disabilities you wish to disclose? *
If yes, please write down which disabilities here: (if no, you may skip this part)
Do you understand that by disclosing a disability, you may be entitled to accommodations? Please answer with "Yes" or "No". *
Do you have any accommodations you wish to request? *
If yes, please write down which accommodations here: (if no, you may skip this part)
Address 1 *
Address 2
Zip Code *
Mail Preference
Telephone (Primary) *
Telephone (Secondary)
Email *
An email you read frequently
Contact Preference *
Clear selection
Clear selection
Official letter of withdrawal
Clear selection
Public Assistance (Choose one or more if "Yes"):
Release of Information Form
I, [Student's Name], am enrolled in Charlestown Adult Education, an Adult Education (AE) program.  The state of Massachusetts pays for this program. This AE program works with other programs to help students improve their skills, get better jobs, and enroll in college or training.  The programs work together to make it easier for students to use their services.  The state needs to know if the programs are helping students achieve their goals.

The information that I provide to this program will be matched against the employment records, GED and HiSET test results, and college and training enrollment so the state can evaluate and improve AE programs and to report results to the federal and state governments. Researchers may use this information to evaluate and improve AE programs. My records will be kept strictly confidential.

Other programs and agencies that the state Department of Elementary and Secondary Education works with are listed below:
•Other adult education programs paid for by the Massachusetts Department of Elementary and Secondary Education
•ETS, HiSET and Pearson GED
•National Student Clearinghouse, public and private colleges
•State executive offices, departments, and agencies including, but not limited to, the Executive Office of Labor and Workforce Development, Department of Unemployment Assistance, Department of Revenue, and Department of Transitional Assistance, MassHire Career Centers and job training programs

With my permission, the AE program that I am enrolling in may use my employment records to evaluate and improve their services. By digitally signing this form, I give permission to the Massachusetts Department of Elementary and Secondary Education to share my data with this AE program.

*Students under the age of 18 must have this consent form signed by the student’s parent or guardian.

(Physical copy of this document must be signed upon arrival to Charlestown Adult Educations physical location. This is a temporary digital copy due to the COVID-19 pandemic school closings.)

Attendance Policy (Temporary COVID-19 Policy)
Currently, due to the COVID-19 pandemic, we are offering our classes online as to comply with the guidance of social distancing. Your attendance will be determined by participation in our Google Classrooms, any measurable dated online activities you are assigned, one-to-one teacher sessions via online platforms, etc. Teachers will provide the names of apps and websites they will use with the class. You may contact your teacher or the program assistant, Jose Alas (, if you have any barriers or difficulties in regards to your participation. Please be aware that this is a temporary Attendance Policy that will expire once classes can be held at our physical location [76 Monument st., Charlestown, MA 02129] once again. At that time you will be required to fill out a physical copy of this from with an updated policy.
Please sign to confirm that you read the Release of Information Form and Attendance Policy, and agree with their contents: *
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