Revised 7/31/17


Today’s Date Your email:


Name

Last, FirstMiddleMaiden


Social Security #
Address

Street City State Zip County

Date of Birth Place of Birth Gender : Female Male


Phone: Home Cell Emergency
Residency
Do you live in a rural area (an area with a population of less than 2500 people)? Yes No
Ethnicity: Latino or Hispanic Origin
Race– Select all that apply:
American Indian or Alaskan NativeAsianBlack or African American
Native Hawaiian or other Pacific IslanderWhite
Adult Level of Schooling
PART A: Highest School Grade Completed (select one):
No school grades completed
Completed one of the following school grades (circle the highest grade completed):
1 2 3 4 5 6 7 8 9 10 11
Completed the 12th grade, but did not attain a diploma or equivalency
Earned a high school diploma
Earned a high school equivalency diploma (GED®)
Have a disability and attained a special diploma or high school certificate of attendance/completion from
completing an Individual Education Plan (IEP)
Completed some college, but did not earn a certificate or degree
Completed college and earned (check one):
a Career Certificate an Associate of Applied Sciences degree
an Associate of Science degree an Associate of Arts degree
a Bachelor’s degree beyond a Bachelor’s degree
PART B: Where was this level achieved? U.S. based school Not U.S. based school


OFFICE USE ONLY
Assessment – Pretest within first 12 hours of instruction
Assessment name: ______Date: ______
Course Title Attendance HoursTeacher
______


Revised 7/31/17


Employment Status(Select one – to be completed upon entry for each term/semester):
Employed
Not in Labor Force (incarcerated, not eligible for employment, or not seeking employment)
Employed but have a Notice of Termination or in transition out of military service
Not Employed (looking and eligible for employment)
Information gathered pursuant to Florida Statute 1006.07 Duties to School Safety and Discipline
Have you ever been expelled from a public school?Yes No
Have you been subject to any stage of the criminal justice system?Yes No
Have you ever been arrested and charged by the court or currently facing charges?Yes No
Are you returning to public school directly from a Juvenile Justice Program?Yes No
A “yes” answer to any of the above items requires completion of a full disclosure statement, which may be obtained from the front office.
Background(Select all that apply – to be completed upon entry for each term/semester):
1. Do you have any reasons (attitudes, customs, practices, etc.) that keep you from being employed? Yes No
2. Are you homeless and/or a runaway? Yes No
If “yes,” please mark the choice that best applies to you:
Lacks nighttime residence Has a normal nighttime residence
Runaway (under the age of 18) Child of a migrant worker
Living in a vehicle, travel trailer park or campground, abandoned building, or other substandard housing
3. Are you currently a migrant or seasonal worker? Yes No
If “yes,” please mark the choice that best applies to you:
Agriculture or fish farming
Traveling farmworker
4. Military status – please mark “yes” or “no” for each of the three responses below:
Yes No Active Duty Member of the uniformed services in your household
Yes No Member or Veteran in your household who was medically discharged or retired for a period of one
year or less
Yes No Member of your household who has died on active duty or as a result of injuries sustained on
active duty for a period of one year or less after death
5. Are you (the student) a single parent? Yes No
If “yes,” please mark the choice that best applies to you:
Single, pregnant, and have at least one other child
Single and have at least one child
Single and pregnant (no other children)
Please mark any of the items below if they apply to you:
Receives Public Assistance
Youth in Foster Care (including aged-out)
Low-income individual (or their dependent) employed primarily in farming, but currently unemployed or finding difficulty
obtaining work for at least 12 months out of the last two years
Child of migrants who have changed school districts in the last 3 years due to parents’ seasonal employment
Previously unemployed or underemployed while caring for home and family (unpaid)
Previously supported by public assistance or family, and now unemployed or underemployed
Parent of a child who has not received TANF benefits (formerly AFDC) in the past two years
Unemployed dependent spouse of a member of the Armed Forces who is on active duty or is deceased or disabled as a
result of military service
The Santa Rosa County School Board adheres to all equity compliance laws prohibiting discrimination and is committed to the policies and practice of non-discrimination on the basis of race, color, religion, gender, age, national or ethnic origin, marital status, disability or genetic identity.


Federal and state legislation requires the provision of accommodations for students with disabilities to meet individual needs and ensure equal access. Adult students with disabilities must self-identify and request such services. Please see a guidance counselor, teacher, or administrator concerning this.

Revised 7/31/17

FERPA NOTIFICATION – Family Educational Rights & Privacy Act (FERPA) Notification –
Student Records
The Family Educational Rights and Privacy Act is a federal law that protects the accuracy and privacy of students’ education records. Student records are confidential. Parents, guardians, and spouses of students who are 18 years of age or older must have the student’s written permission to inspect
and review any and all official records. Parents/ guardians of students 17 years of age or younger may review their child’s records upon request.

The Family Educational Rights and Privacy Act (FERPA), Florida Statues (F.S.) 1002.22 and 10022.221 affords parents, guardians or eligible students certain rights with respect to student education records.
An “eligible student” means a student who has reached the age of 18 or who is attending a post-secondary institution at any age. Once a student becomes an “eligible student,” the rights afforded his or her parents under FERPA transfer to that student. For additional information, please visit the Family Policy Compliance Office (FPCO) site link at: Paper copy available upon request.

Personal and confidential information:

  • Will be shared only among the WIOA core program partner staff and subcontractors;
  • Will be used only for the purpose of conducting an employment data match and that further disclosure of personal confidential information or records is prohibited; and
  • Will not be shared among WIOA core partners if the individual declines to share personal confidential information or records and that declining to share will not impact eligibility for services.

Where did you learn about our program?
Friends and Family Website One Stop Center
Social Media School Counselor
What goal do you hope to accomplish by taking this class?
Obtain or Retain Employment Prepare to enter a Post-Secondary program
Improve Employment Skills
CODE OF CONDUCT STATEMENT:
I understand that I am responsible for abiding by the Santa Rosa County School District’s Code of Student Conduct
as well as the Santa Rosa Adult School Student Handbook. Both of these documents can be found online at
Additionally, these documents are available in print upon request.
I understand that in accordance with the Student Progression Plan for the Santa Rosa County District Schools, once I
enroll in an adult education class I may not return to a traditional Santa Rosa County high school.

I certify that all information on this application is true and accurate to the best of my knowledge.
Florida Statute 837.06: Whoever knowingly makes a false statement in writing with the intent to mislead a public
servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable
as provided in s. 775.082 or s. 776.083.

RELEASE OF RECORDS AND TEST SCORES:
Santa Rosa Adult School has my permission to share my academic records and test scores (including GED®
scores) with teachers and administrative staff for educational purposes.
Upon diploma completion, Santa Rosa Adult School has my permission to print my name in the graduation
program and in local newspapers.
Student signature ______Date ______