Please fill out the form: (* denotes required fields)
First Name *
 Last Name *
Middle Name
 Suffix
Program * (must select at least one)
SASID
 Residence Area
Country Born *
 Birthdate *
Gender *
 Native Language *
Race * (must select at least one)
 Ethnicity * (must select at least one)
Highest Education Level Completed on Entry: *
Write in the grade level:
Write in the grade level:
Last High School Attended *

 Highest Education Level Location *
Employment Status *
 Miscellaneous Characteristics (Check all that apply)
Which of the following do you have at home so that we can contact you and/or connect you to services? *
Home Street Address *
City *
 Zip Code *
County *
 State *
Phone Number *
Enter Phone Number *
 Email Address *
Parent/Guardian of: (Check all that apply and list number)
If yes, how many?
If yes, how many?
If yes, how many?
I understand: *

Emergency Contact

Name of Emergency Contact *
 Emergency Phone *
Relationship to Emergency Contact *

Employment Information

Name of Employer
 Employer Address
Employer Phone
All students must check one category below: *
Low-level Literacy
ABE, GED, NEDP, CDP students
(All students who do not have an SSD at entry)
 English Language Learner/Cultural Barriers
ESL/ELL students

Check all that apply: *

Cultural Barriers *
Do you feel your culture, beliefs, or practices makes finding/keeping a job harder?
Disabled *
Do you wish to disclose any disability that limits your life activities?
Displaced Homemaker *
Are you a former homemaker who is having trouble finding a job or a better job?
Low Income/Public Assistance *
Do you have a low income? Do you receive SNAP, TANF, SSI, or local public assistance? Are you a foster child or homeless?
Ex Offender *
Do you have a criminal record that makes it hard to find a job? (Do not select this category if you are currently incarcerated)
No TANF within 2 years or less *
Within two years, will you no longer be eligible to receive Temporary Assistance for Needy Families (TANF) benefits?
Foster Care Youth *
Are/were you in the foster care system and are under 24 years old?
Homeless or Runaway Youth *
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?
Long Term Unemployed *
Do you have a low income? Do you receive SNAP, TANF, SSI, or local public assistance? Are you a foster child or homeless?
Migrant and Seasonal Farmworker *
(if yes, select a subcategory)
Dislocated Worker *
Have you been fired or laid off? Are you unemployed because the place where you worked has closed?
Single Parent or Guardian (or single pregnant woman) *
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?

How did you hear about Adult Education?

Upload important documents (Driver's License, Passport, and/or proof of residency):


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

Applicant Signature *
 Date *

Enter the code shown above. *
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Hamden Adult Education highlights student achievement by photographing and videoing a variety of curricular activities. Photographs and videos are published online and in print and may list student names. Hamden Adult Education publicity is separate from any newspaper, media or community organization. This option applies only to Hamden Adult Education publications such as the website and social media, etc.

Select one: *