Adult Learning Plan

Adult Learning Plan
PLAINWELL COMMUNITY SCHOOLS 2018-2019
Program*
High School DiplomaHigh School Equivalency (GED)English Speakers of Other Languages (ESOL)RemediationUnsure
Instructor*
Campus*
where classes are held
How did you hear about us?
Are you interested in free training in welding, nursing assistant, construction, or CNC machining?
Yes - talk to your instructor ASAP!NoUnsure - want more information
Participant Enrollment Information
This information is required to enroll you into our program.
Name*
First NameMiddle InitalLast Name
Maiden Name
Address*
Street Address
Street Address Line 2
CityState
Zip Code
County
Phone Number*
Area CodePhone Number
E-mail
Date of Birth
Age
Social Security Number (no spaces or dashes)*
Sex*
MaleFemale
Last School Attended (please include city and state)*
Emergency Contact Information
Please complete this information for one emergency contact person
Emergency Contact Name*
First NameLast Name
Relationship to Participant*
Does your emergency contact live with you?
YesNo
Emergency Contact's Address*
Street Address
Street Address Line 2
CityState
Zip Code
Emergency Contact's Phone Number*
Area CodePhone Number
Demographic Information
Number of Pre-school-aged children (ages 0-5)*
Number of K-12 School-aged children*
I have a child/children enrolled in Plainwell Community Schools*
YesNo
If yes, how is your child currently performing in school?
Veteran?*
YESNO
Hispanic/Latino?*
YESNO
Racial Group*
Black or African AmericanAmerican Indian/Alaskan NativeAsianNative Hawaiian/Pacific IslanderWhite
U.S. Based Schooling*
U.S. Based SchoolingNon-U.S. Based Schooling
Highest Level of Education Completed*
No SchoolingGrades 1-5Grades 6-8Grades 9-12 (no diploma)HS Diploma/equivalentSome postsecondary (no degree)Postsecondary or professional degreeUnknown
Employment and Barrier Information
Please Check all Barriers That Apply to You*
Child careCultural BarriersCurrent/Prior Foster Care YouthDigital LiteracyDisabled (physical/mental)Displaced HomemakerExhausting TANF within 2 yrsEx-OffenderHomelessLearning DisabledLong-term Unemployment (27+ weeks)Low IncomeMigrant/Seasonal FarmworkerSingle ParentSubstance AbuseTransportationNone of Above
Employment*
EmployedEmployed - received termination notice or military separationUnemployed (seeking work)Unemployed (not seeking work - not in the labor force)
Place of Employment
Current Wage
Specify per hour, week, month, or year.
Number of Transferable HS Credits Previously Earned
Number of HSE Exams passed (2014 or later only) Previously
To Be Completed by Teacher
Educational Gain Goal*
Improve Basic Literacy Skills (HSD/GED)Improve English Skills (ESL)
Academic Proficiency Goal
Function at or above the 9th Grade level (ABE)Obtain English language proficiency (ESL)None of the Above
Educational Credential Goals*
Obtain high school creditsObtain high school diplomaPass one or more official HSE testsObtain HSE certificateEnglish Language Proficiency CertificateComplete Mathematics and/or Reading Remediation
Other Goals
Achieve Citizenship SkillsVote or Register to VoteLeave Public AssistanceIncrease Involvement in Children's Education
Post-secondary Goals
Obtain employmentRetain or improve employmentEnroll in post-secondary schoolingNone of the Above
By signing below, I agree to be enrolled at Renaissance Adult Education as a student. I agree to allow Renaissance Adult Education to request school records and keep them on file and to share my records with other entities as approved by the participant.
I agree to allow Renaissance Adult Education to take my photo and use my image for non-profit purposes unless otherwise stated. If you do not want your photo to be taken and used for marketing or social media, please submit a request in writing.
I agree to allow Renaissance Adult Education to share assessment scores, employment status, or any other non-sensitive information to partners like Michigan Works or Michigan Rehabilitation Services as needed to meet the needs of the participant.
I understand that I must familiarize myself with the poicies of Plainwell Community Schools, including but not limited to: technology use both on-site and off-site, building use, not smoking on school property, creating a positive and supportive environment for both participants and staff while in class.
I have received a student planner which within details the policies of the program and agree to abide by these policies.
I understand that in order to remain enrolled, I must be active online and in class, I have to communicate regularly with my instructor, I must take a pre-test and post-test, (post-test after 40 hours of instruction) and abide by all building and school district policies and rules.
* Si necesito un intérprete para entender este contrato, solicitaré uno ahora.
* Se eu precisar de um intérprete para entender este contrato, solicitarei um agora.
* Si j'ai besoin d'un interprète pour comprendre ce contrat, j'en demanderai un maintenant.
* ဤစာချုပ်ကိုနားလည်ရန်စကားပြန်လိုအပ်ပါကကျွန်ုပ်အားယခုတောင်းခံပါလိမ့်မည်
* إذا كنت بحاجة إلى مترجم لفهم هذا العقد ، فسأطلب عقدًا الآن
* 如果我需要口譯員來了解這份合同，我現在將要求

I hereby agree to these terms.
Type your full name here to acknowledge agreement
Clear
Please Include a Photo of your Identification Now
Take a photo of your ID now
Should be Empty:

Adult Learning Plan

Participant Enrollment Information

Emergency Contact Information

Demographic Information

Employment and Barrier Information

To Be Completed by Teacher

Please Include a Photo of your Identification Now