PCSSD Adult Education 2020-21 Student Intake Form
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Email *
Start Time: *
Staff Name *
Site Name/Location - LEA - Pulaski County Special School District *
Date *
Last Name *
First Name *
Middle Initial
Social Security Number
This field is NOT required. If a student provides a SSN, however, that student will need to bring in documentation to verify that the SSN is correct.
Program Type
WAGE Program? *
ESL Student? *
Residence Area *
Date of Birth *
Gender *
16/17-Year-Old *
Score of 535 on TABE level A or D?
Clear selection
Citizenship Test Completed
Clear selection
Student Keyword *
Ethnicity - Hispanic/Latino? *
Race *
Highest Grade Level Completed *
Location *
Last Month/Year Attended
Employment Status at Program Entry *
Barriers to Employment? *
Most students seeking adult education services have at least one barrier to their employment. The number of barriers that students face impacts the benchmarks that state adult education programs are measured with by OCTAE. A state whose adult education students face a significant amount of barriers is held to different minimum standards than a state whose adult education students face fewer barriers. For this reason, it is important that you carefully discuss these with students, and select as many that may apply.
If yes, select all that apply *
Military Service Experience *
Notified of Selective Service Obligation? *
Street Address (City, State, Zip Code) *
County of Residence *
Phone Number
Email Address
Correctional *
Institutional *
Apparent or Disclosed Disabilities
Clear selection
Specific Learning Disability
Clear selection
Data Sharing Agreed *
If students agree to Data Share, this allows us to perform a Data Match with educational institutions after the student exits your program, as a way of tracking the effectiveness of our adult education programs. Despite the name, student data is NOT shared with anyone, and will not be used to solicit them in any way.
Country of Birth *
First/Native Language *
How Did the Participant Learn About The Program? *
Referring Agency *
Valid Driver's License? *
Reliable Transportation? *
Registered to Vote? *
Release of Confidential and /or Academic Information - I authorize PCSSD Adult Education to use my name and/or photo in the following matter. Please check all that apply. *
I, as a PCSSD Adult Education Student, understand the following testing policy. 1. A student with a NRS score of 1 to 4 on the TABE will be post-tested after 40 classroom hours of attendance (virtually or face to face). 2. A student with a NRS score of 5 or 6 on the TABE will be post-tested after 30 classroom hours of attendance (virtually or face to face). 3. ESL students will be post-tested after 40 classroom hours of attendance. There will be NO early testing for any reason unless the student or site has been notified and approved by early post-test waiver. *
STUDENT HANDBOOK - PCSSD Adult Education has made available the Student Handbook online for your viewing and downloading. The student handbook is available on our website at www.gedwage.com and a hard copy at your request. Please sign below that you acknowledge that you have been informed of the handbook and that you will abide by the Conduct and Discipline and will adhere to while at school face to face, virtually or any school activities. In the event that I am not entirely certain of some aspect of school policy, I will contact the administration for clarification within one (1) week after receipt of that policy. Your electronic signature certifies that you received information in regard to accessing the Student Handbook from the school you attend or through your Distance Learning teacher. *
End Time: *
Intake Hours: *
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