Adult Workforce Education Program Application
A non-refundable application fee is due with the application form. The application will not be considered nor will an applicant be permitted to test until the fee is paid in full.

Students under the age of 18 must have this consent form signed by the student’s parent or guardian.
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Program *
Name *
Address *
City *
State *
Zipcode *
Phone *
Email *
Education: Please check the highest level of education you have achieved *
Required
If no diploma has been earned, please note the highest grade you have completed
If you have received your GED, please note the completion date
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If you have received your high school diploma, please note the school, city, state, and graduation date
If you have received a higher degree, please note the school, major, and year completed
The state is requiring registration with OhioMeansJobs.com, including individuals: Participating in adult career technical education programs;  Accessing vocational rehabilitation services through Opportunities for Ohioans with Disabilities; Utilizing Adult Basic and Literacy Education services; and Receiving employment services as an injured worker through the Bureau of Workers’ Compensation. For a complete list of who needs to register with Ohio Means Jobs, please go to http://workforce.ohio.gov/initiatives/CombinedStatePlan.aspx and select the 2015 fact sheet.
Have you registered with Ohio Means Jobs? *
Is this your first post-secondary educational experience?
Clear selection
We appreciate your cooperation in completing this data survey that is needed to comply with federal and state regulations. Please place an “X” on the appropriate line that describe you according to the definition listed in the questions below.
Gender
Clear selection
Date of Birth
Ethnicity
Clear selection
Please mark all that apply:
Adult Workforce Education Emergency Information & Medical Authorization
Student Name *
Student Home Address *
Student City *
Student State *
Student Zipcode *
Student Home Phone *
Student Cell Phone *
Student Date of Birth *
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Contact Person Name *
Contact Person Relationship to Student *
Contact Person Home Phone *
Contact Person Cell Phone *
Contact Person Business Phone *
If unable to contact the person listed above, please contact (Second Contact Name): *
Second Contact Home Phone *
Second Contact Cell Phone *
Second Contact Business Phone *
Part 1 Grant Consent: I hereby give consent for the following medical care providers and local hospital to be called and utilized: (list “any” if no preference)
Physician Name *
Physician Phone *
Dentist Name *
Dentist Phone *
Medical Specialist Name *
Medical Specialist Phone *
Local Hospital Name *
Local Hospital Phone *
Facts concerning my medical history, including allergies, medications being taken, and any physical impairment to which a physician should be alerted *
In the event reasonable attempts to reach individuals listed have been unsuccessful, I hereby give my consent for (1) the administration of anytreatment deemed necessary by above named doctors, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist, nurse, emergency medical technician or other qualified professional and (2) the transfer to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
Part 2: Refusal to Consent
I do not give my consent for emergency medial treatment. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action:
Family Educational Rights and Privacy Act (FERPA)
The Family Education Rights and Privacy Act of 1974 gives students control over the release of their Educational records. In order to release student information, their permission is required. Students are asked to sign a release statement for various reasons. Students may opt to sign one section of the release statement and note the other or none at all. The following is a list of potential reasons records that may be released. Records or pictures will only be released in instances where students have signed the appropriate section.1)Because our school is accredited or in candidacy status by several agencies: NCA, CASI AdvanceED,Ohio Dept. of Public Safety, National Registry and under the U.S. Dept. of Education and Ohio Board of Regents, any audits performed by these agencies may involve the systematic review of student records. While confidentiality of these records is maintained, personnel assigned from these agencies will at various times have to access these records to ensure that Ohio River Valley Adult Education is providing the required documentation and following processes as outlined. Signature of this section indicates approval of review of records for such said purpose. Typing my name below constitutes my agreement and signature.
2) Students may authorize Ohio River Valley Adult Education to release and share the following information to any agency requiring information pertaining to their participation in training or where there is an educational need to know. For instance, this may include but not be limited to: Ohio Job and Family Services, or WIA, Veterans Affairs, Rehabilitation Services commission, a specific company, contracts, legal counsel, school board, teachers, and/or administrators. A. Grades or progress records issued for participation in training, including any notices of academic standing, including dates of attendance. B. Assessment results or enrollment status. C. Financial aid and/or individual pay account records for agency verification. D. General information regarding inquiries for employment during or after the completion of my education. E. Telephone number. Such release shall be for information relevant to training and/or education costs for effective monitoring of a student’s training progress by all agencies concerned. Students sign indicating that they understand their right to privacy and waive this right for the purposes identified above. Typing my name below constitutes my agreement and signature.
3) Students may sign a statement of release for awards or special recognition received, so that this may be released and used with area media for publicity; this could include a photograph and might be placed on the internet, our website or in print to local newspapers. Typing my name below constitutes my agreement and signature.
Release of Information Form
I hereby authorize the Ohio Department of Education to release my educational records, which includes my name, social security number, student ID number, and date of birth to the agencies listed below. The agency use of these records is limited to and in connection with the audit and evaluation of Federally supported education programs, or in connection with the enforcement of the Federal legal requirements, that relate to such programs.Student/Examinee information released to:Ohio Department of Job and Family Services Ohio Board of Regents145 South Front St. 30 East Broad StreetColumbus, Ohio, 43215 Columbus, Ohio, 43266-0417. My signature is my acknowledgement that I have read and voluntarily consented to the release of the above mentioned educational records as collected and utilized by the adult workforce education programs I have previously enrolled in or tested with. Typing my name below constitutes my agreement and signature.
Please enter your Social Security Number for the release of records. Use of Social Security Number is optional. If you choose to give us your Social Security Number, we will use it to maintain your file and assure prompt and accurate reporting.
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