Adult Education Information Form 2025-2026

Do you have an email address?

YesNo

Pronouns

Do you have an Social Security Number?

YesNoPrefer not to answer

Social Security Number

Other ID Type

Driver's LicenseVisaPassportPrefer not to answer

Do you have a permanent address?

YesNo

Emergency Contact Name

Emergency Contact Telephone

Last High School Attended

Parent/Guardian of (Check all that apply)

Child(ren) 5 years and youngerChild(ren) 6 to 10 yearsChild(ren) 11 to 18 years

Number of Children 5 years and younger

Number of Children 6 to 10 years

Number of Children 11 to 18 years

Public Assistance (optional)

General Assistance (SAGA)Temporary Aid for Needy Families (TANF/TFA) or equivalentNone

Rural/Urban Status

RuralUrban/High Unemployment

Miscellaneous Characteristics (check all that apply)

Are you seeking a high school diploma or equivalent?

YesNo

Are you seeking classes to improve your English language skills and/or for help with obtaining citizenship?

YesNo

Do you have a criminal record or previous incarceration that makes it hard to find a job?

YesNo

Within 2 years, will you no longer be eligible to receive Temporary Assistance for Needy Families (TANF) benefits?

YesNo

Are/were you in the foster care system and are currently under 24 years old?

YesNo

Are you homeless or live in a motel/hotel, campground, transitional housing or with another person because you lost your house or apartment?

YesNo

Have you been unemployed for 27 weeks or more (over 6 months)?

YesNo

Do you work on a farm?

YesNo

I am a seasonal farmworker who has worked in the last 12 months in agriculture, fish, or on a far

I am a seasonal farmworker with no permanent residence

I am a dependent of a farmworker

Are you a single parent, unmarried, or separated and have primary responsibility for one or more children under age 18, or are you a single, pregnant woman?

YesNo

Do you have a low income and/or receive SNAP, TANF, SSI or local public assistance? Are you a foster child or homeless?

YesNo

Are you a former homemaker who is having trouble finding a job or a better job?

YesNo

Have you been fired or laid off? Are you unemployed because the place where you work has closed?

YesNo

Do you wish to disclose any disability that limits your life activities?

YesNo

Do you feel your culture, beliefs, or practices makes finding/keeping a job harder?

YesNo

Please select the technology below that you have available to use for class(es) (check all that apply)

How did you hear about us? (check all that apply)

I have accessed and read the EASTCONN Student Handbook

I understand that student information is confidential and it will only be used for program administration purposes.

Message to Tech Support

Adult Education Information Form 2025-2026

Adult Education Information Form
Please fill this form out and we will get back to you as soon as possible.

2025-2026 STUDENT HANDBOOK

Adult Education Information Form 2025-2026

Adult Education Information Form Please fill this form out and we will get back to you as soon as possible.

2025-2026 STUDENT HANDBOOK

Adult Education Information Form
Please fill this form out and we will get back to you as soon as possible.