• Arizona Adult Education Participant Registration

  • Eligibility for Services

  • A.R.S. §15‐232(B) states that “The Department of Education shall provide classes under this section only to adults who are citizens or legal residents of the United States or are otherwise lawfully present in the United States. This subsection shall be enforced without regard to race, religion, gender, ethnicity or national origin.

  • I affirm under penalty of perjury that I am a citizen of the United States, a legal resident of the United States, or otherwise lawfully present in the United States. Should my status change, I understand that it is my responsibility to withdraw from classes until such a time that I am again lawfully present in the United States.

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  • PARTICIPANT NAME

    Enter the participant’s LEGAL NAME as it appears on the presented identification.
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  • Mailing Address

    Participant’s full street address, including apartment number or “care of” (c/o) information. Please use abbreviations to make sure the information fits.
  • Demographic Information

    The US Department of Education requires that we report on the following demographic information
  • Do any of the following situations apply?

    (Mark Yes or No to each question)
  • Veteran of the Armed Forces

    (any person who served honorably on active duty in the armed forces (Army, Navy, Air Force, Marine Corps, and Coast Guard) of the United States.) Mark Yes/No to each question. One or Both must be marked as Yes
  • Location and Employment

  • Validity of Information

  • By signing below, I represent that the information I have provided in this declaration and document is true and correct and that any document(s) I present are genuine. I understand that false or misleading information or documents related to this declaration may subject me to expulsion from the program as well as other legal actions.

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  • Family Education Rights and Privacy Act Release

  • To attend adult education programs funded through the Arizona Department of Education (ADE), the participant must allow his or her information to be entered into and shared with designated adult education data systems, including the state-mandated testing platform, and all Workforce Innovation and Opportunity Act (WIOA) Core Partners’ data systems. This information will be shared with any ADE-funded adult education programs in which the participant enrolls, the participant’s instructors, and the Arizona Department of Education. This information is used for program operations, student instruction, employment opportunities, and to compile federal and state reports of non-identifying aggregate student data.

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  • My signature below verifies my acceptance that I have reviewed and understand the policies associated with enrolling in courses at CCC. I understand Coconino Community College may request documentation from me to confirm the information I have provided.

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  • Should be Empty: