FY2025 Adult Education Student Intake Form
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Intake Date (Today's Date): *
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Social Security Number: (optional)
Last Name *
First Name: *
Middle Name/Initial:
Suffix:
Example: Jr., Sr., The 3rd, etc.
Service: *
(Check the ONE that BEST APPLIES.)
Required
Secondary Service (select No if you want ESOL or HiSET/GED): *
Required
WIOA Core Program (Check one):
Date of Birth: *
If under 18, an official letter of withdrawal from a High School is required to take the official HiSET/GED tests. We will help with this.
MM
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DD
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YYYY
Country of Birth: *
Sex: *
Gender Identity: *
Pronouns: *
Are you Hispanic/Latino? *
What is your race? (Check ALL That Apply): *
Required
Were you ever enrolled in MA public education (K12, Adult Education, Community College)? *
Highest educational level completed on entry: (Check only one) *
Where did you receive your highest level of education? (Check only one): *
Employment Status at Program Entry: (Check the one that best applies): *
Barriers to Employment: *
(Check ALL that apply. Must select at least either “English Language Learner” (ESOL) or “Low Literacy Levels” (HiSET))
Required
Address 1 *
Address 2
Zip Code *
City *
State *
Mail Preference:
Which of the following do you have at home so we can contact you and/or connect you to services? (Check all that apply):
Telephone (Primary): *
Telephone (Secondary)
Email *
An email you read frequently
Contact Preference: *
Required
Correctional (AECI only):
Institutional (AECI only):
Students with Disabilities
This Adult Education program does not discriminate on the basis of disabilities. Applicants may disclose any disabilities they have but are NOT required to do so. If applicants opt to disclose a disability, they may be entitled to accommodations. Please answer the following questions:
Do you have any disabilities you wish to disclose? *
If yes, please write down which disabilities here: (if no, you may skip this part)
If yes, please write down which accommodations here: (if no, you may skip this part)
Official letter of withdrawal on file (if under 18)
Public Assistance (Choose one or more if "Yes"):
Scheduling Preferences:
Preferred Instructional Mode (Choose one or more):
Where did you hear of us?
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.)

Please sign to confirm that you read the Release of Information Form and Attendance Policy, and agree with their contents: *
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