Urbana Adult Education Center Registration
2021-2022 School Year
Email *
If you need assistance with this form, please visit our office at 211 N. Race St. and we will assist you.
Si usted necesita ayuda con este formulario, visite nuestra oficina en 211 N. Race St. y lo ayudaremos.
Si vous avez besoin d'aide avec ce formulaire, veuillez visiter notre bureau au 211 N. Race St. et nous vous aiderons.
How did you hear about our programs? (check all that apply) *
Required
Last Name *
First Name *
Middle Name *
Please choose one: *
If you have a social security number, provide it in the space below. A social security number is NOT required for enrollment.
Date of Birth *
MM
/
DD
/
YYYY
Age *
Street Address (including apartment or building#) *
City *
Zip Code *
County *
Phone Number *
Who should we contact in case of an emergency? *
What is your emergency contact's phone number? *
What is your relation to your emergency contact? *
Gender *
Please note: Unfortunately, our funding source requires this information for data purposes and does not allow us to offer any additional options for those who do not identify as part of this binary. We sincerely apologize that we cannot offer additional categories. Please know that we will use your preferred pronouns despite the fact that we cannot offer addiitonal options for the purposes of this form.
Race (check all that apply): *
Required
Primary Racial Identification (choose only one): *
What is your native language? *
Are you an English language learner? *
Employment Status: *
If employed, what are your average hours per week?
If employed, where are you employed?
If employed, what is your job title?
What is your yearly household income? *
Where did you last attend school? *
How many years of school did you complete? (do not include college years). *
Educational History (choose all that apply to you): *
Required
Do you receive public assistance (e.g. TANF, SNAP, WIC, SSDI, etc.) *
Do you have any of the following barriers to employment and/or education? (choose all that apply to you): *
Required
Disability Status: *
Are there any health concerns we should know about? If so, please list them below. *
Do you have at least one child that attends school in Urbana School District #116? *
Internet Access: please indicate which statement best applies to you. *
Technology: please indicate the devices you could use for remote learning (check all that apply). *
Required
Which program are you interested in? *
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