Intake Form – ConnectAble Demo

One of the first steps our students take is to fill out our registration form.

Please tell us more about yourself in the form below. The information provided can help us to match you with great resources that can help you along your journey.

As always with us, your answers will be kept completely confidential.

The ConnectAble Difference

The intake form can be challenging, especially for lower level students or new English learners. The result is often incomplete, inaccurate, or unsigned forms. Here is how ConnectAble solves those issues:

We make the intake form itself fully translatable so that the student can experience it in his/her native language. (Try it by choosing a language from the menu dropdown).
We break the form into manageable sections.
We use smart logic in our forms, giving the students questions based on their previous answers.
We require that all fields be completed, including the electronic signature, before the form can be submitted.

This is a sample form. Feel free to complete it if you would like.

Program Year 2021-22 ConnecAble Learner Registration Form

STUDENT INFORMATION
PROGRAM YEAR 2021-22
Name
Please carefully type your legal name.
First Middle Last
Social Security Number:
We do not require you to provide your social security number, but providing it helps us to track your accomplishments as well as any resources we might be able to provide for you. As always, we keep all of our data secure.

Are you currently a student at any high school)?

Yes

No
PLEASE NOTE: You will not be able to submit this form if you are currently a student at any high school.
According to state policy, students who are currently enrolled in a high school cannot also be enrolled with us.
If you wish to exit your current program so that you may join our program, click here to download and complete the required exit form., then turn the completed form in to our office.
Are you currently on an F1 student visa?

Yes

No
PLEASE NOTE: You will not be able to submit this form if you are currently on an F1 Visa. We will be happy to serve you if that status changes. To learn more about the rules for student visa’s click following link: Click here to learn more.
Address
Street Address City State ZIP Code

County:

Marion County

Carrol County

Clinton County

White County

Are you a US Citizen?
We accept ALL students, regardless of which citizenship status you choose. Clicking NO will not prevent you from enrolling with us.

Yes

No
Country of Birth:

Mobile Phone Number
We communicate important messages to students via text message. If you do not currently have a mobile phone, please list a phone number of a trusted family member or friend so that you can receive messages.
Email:
Enter an email address you can access easily and check frequently. If you do not have an email, click here for instructions on how to create one..

Date of Birth
Age:
To enroll, a 16 or 17-year-old student must have a signed exit interview from his/her school district upon registration with us. We also need parent or guardian signatures, so parents/guardians need to accompany their 16 or 17-year-old children for registration.

Click Here to Download Exit Interview Form
To be able to take the test to earn a High School Equivalency diploma, a 16 or 17-year-old student will also need a Superintendent’s Recommendation form signed by his/her school district’s Superintendent before he/she can test with us. If you are unable to obtain that Superintendent’s signature, let us know and we can help get it completed.

Click here to download the Superintendent’s Recommendation form.
Gender

Male

Female

Non-binary
Please list any other legal names you have had in the past.
For example, if you are married and your last name has changed, list your previous last name here. If you have never had a different name, leave it blank.

ETHNICITY:
NOTE: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race, refers to Hispanic ethnicity. Please select the option below that describes your ethnicity.

Hispanic

Not Hispanic
Race:
Please select all that apply.
African American
Asian
American Indian
Pacific Islander
White
None of these describe me.
Name of Emergency Contact:
Who can we contact if we cannot reach you?
First Last
Emergency Contact's Phone Number
Employment Information
Employment Status: (Choose the one that best describes you.)

I am NOT IN THE LABOR FORCE, as I am not working, not able to work, or not looking for a job.

I am able to work but am currently NOT EMPLOYED.

I am EMPLOYED, BUT MY JOB IS BEING TERMINATED.

I am EMPLOYED.
Have you been unemployed for more than 26 weeks?

Yes

No
Employer:

Employer Phone:
Educational Information
Educational Status:
Please check the highest level of education you have completed.

No schooling

Grades 1-5

Grades 6-8

Grades 9-12 (no diploma)

High School Certificate (Disability/IEP)

High School Diploma or alternate credential

HSE (High School Equivalency) / GED

Some college (no degree)

Professional Licensing/Career Certification (no degree)

College Degree (Associate’s Degree)

College Degree (Bachelor’s Degree)

College Degree (beyond Bachelor’s Degree)

Unknown
Last Grade Completed
Please list the last grade level (1-12) that you completed. *If you have completed education beyond high school, you can list “12+” as your last grade level completed.

Last School Attended:
Please type the name of the last school you attended.

Previous Schooling Location:
Where did you complete most of your schooling so far?

U.S.-based schools

Non-U.S.-based schools
School Attendance Status at Entry:
Select the option that BEST describes your current school situation:

In-school: Grades k-12

In-school: Alternative School

In-school: Postsecondary (beyond 12th grade)

Not attending school: 18 or older and did not not finish high school

Not attending school: Received a high school diploma, GED, or HSE

Not attending school – Under 18 years old
Household Information
Current Enrollment Type:
Which of the statements below describe your main reason for coming to school as of right now?

I want to learn English.

I want to improve my academic skills, access career training, or earn a High School Equivalency (HSE) diploma.
Residential Institution:
Please select the option that describes your residential situation.

Correctional Facility

Community Corrections Facility

Medical Facility/Group Home/Nursing Home

None of these apply to me.
Method Found:
How did you learn about us?

TV/Radio

Newspaper

Brochure/Flyer

Department of Workforce Development

Public Assistance Referral

Literacy Program Referral

Court Referral

Other Referral

Employer

Shelter

DWD Website

WorkOne Referral

School Website

Demographics
Check any of the following that apply to you:
I have some impairments (Physical, Mental, or Learning).
I live in an urban area. (I live in the city; Housing, businesses, and shopping are close to me.)
I live in a rural area. ( I live outside of the city, far away from housing, businesses, and shopping.)
I receive public assistance. (SSI, SNAP, TANF, WIC, etc)
I have a low income.
I am a displaced homemaker. (I was a homemaker but now have to enter the workforce due to a change in circumstance).
I am a single parent.
I am a dislocated worker. (I lost my job due to my employer moving locations.)
I am a dependent, or I have dependent(s).
I am a foster care youth (age 16-24 and either in foster care or aged-out of it).
I am homeless or a runaway.
I speak a language other than English at home.
Annual Family Income (yearly income before taxes):
We are asking this information for the purpose of finding resources for you. We accept all students, regardless of family income.
Household Size
How many people live in your household, including yourself?
What is the language you first learned as a child?

We have many resources to help our students overcome barriers that might make it difficult to come to school. Please select any of the issues listed below that you might need assistance with, as we may have resources that can help! Select all that apply.
Transportation Assistance
Food Assistance
Immigration Information
Child Care Assistance
I don’t need any help with these things.
Migrant/Seasonal Farm Worker:
Please select the option that best describes you:

This does not apply to me.

Migrant Worker

Migrant and Seasonal Worker

Dependent of a Migrant/Seasonal Worker
Active Military:
Please select the option that best describes you:

This does not apply to me.

I am active military.

I am the spouse of active military.
Are you involved in a Vocational Rehabilitation agency?
Please select the option that best describes you.

No

Yes

VR & E

Both VE and VR & E

Unknown
Wagner Peyser Employment
Wagner-Peyser employment refers to a federally-funded program that connects employers with job seekers.

Yes

No

Unknown
Ex-Offender
Have you ever been convicted of a crime?

Yes

No

Unknown
Cultural Barriers to Employment
Do you have any cultural barriers that affect your job opportunities?

Yes

No

Unknown
Release of Information
I am enrolling in an Adult Basic Education (ABE) program. This ABE program works with the following programs and agencies to help students improve their skills and earn better jobs:
• Other state-funded adult education programs
• WorkOne offices and job training programs
• Public and private colleges
• State executive offices, departments, and agencies, including the state Department of Workforce Development (DWD), Division of Adult Education and the Department of Education.

By signing below, I understand and agree to the following:
• The information on my intake form is correct.
• DWD use of directory information (name, address, birth, and social security number) to match test score records, wage information, and college/training program enrollment records that assist the state to evaluate and improve its programs and to report results to the federal and state government.
• The sharing of information between the agencies and programs listed above. This information may include my name, enrollment information, education/career goals, test scores, and employment history. The information will be kept strictly confidential and will be used for program administration, research, and evaluation purposes.
I agree to the Release of Information described above.

Yes
Photo Release
We love to celebrate success with our students, and we often do that through pictures, articles, slideshows, and other fun media. In order for you to participate in that, we will need permission to use your photo.
I grant ConnecAble Adult Education Academy, its representatives and employees the right to take and/or use provided photographs of me in connection with documents and promotional materials published by the same. I authorize ConnecAble Adult Education Academy, its representatives and employees, to use and publish the same in print and/or electronically. I agree that ConnecAble Adult Education Academy may use such photographs of me with or without my name for purposes including training and instruction manuals, promotional materials, and electronic documents.
Student Photo Release

I agree to the above photo release statement.

I do not agree to the above photo release statement.
Student Contract Agreement
I have read, and I agree to abide by, the rules in the ConnectAble Adult Ed Academy student contract, which can be found at demo.getconnectable.com/student-contract-page for current and future reference.

Yes
Electronic Signature
Typing your name in the fields below will constitute your electronic signature(s) for the above provided information. Please verify that all information is accurate before you sign. Applicants who are under 18 years of age will require a parent/guardian signature as well.
Signature
Please type your full name, as this will serve as your electronic signature. This signature acknowledges that the information provided in this form is correct.

Parent/Guardian Signature
Parent/Guardian, please type your full name, as this will serve as your electronic signature. This signature acknowledges that the information provided in this form is correct.