JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Urbana Adult Education Center Registration
2021-2022 School Year
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
If you need assistance with this form, please visit our office at 211 N. Race St. and we will assist you.
Si usted necesita ayuda con este formulario, visite nuestra oficina en 211 N. Race St. y lo ayudaremos.
Si vous avez besoin d'aide avec ce formulaire, veuillez visiter notre bureau au 211 N. Race St. et nous vous aiderons.
How did you hear about our programs? (check all that apply)
*
School District/ High School
WorkNet/One Stop Center/WIOA
Flyer
Social Media (Facebook, Twitter, Instagram, etc.)
Friend/Family
Community Organization (church, social service agency, etc.)
Employer
Other:
Required
Last Name
*
Your answer
First Name
*
Your answer
Middle Name
*
Your answer
Please choose one:
*
Choose
I am new to Urbana Adult Education.
I am a returning student/I have attended Urbana Adult Education sometime in the past.
If you have a social security number, provide the last 4 digits in the space below.
A social security number is NOT required for enrollment.
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Street Address (including apartment or building#)
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
County
*
Champaign
Ford
Vermillion
Piatt
Macon
Other:
Phone Number
*
Your answer
Who should we contact in case of an emergency?
*
Your answer
What is your emergency contact's phone number?
*
Your answer
What is your relation to your emergency contact?
*
Your answer
Gender
*
Please note: Unfortunately, our funding source requires this information for data purposes and does not allow us to offer any additional options for those who do not identify as part of this binary. We sincerely apologize that we cannot offer additional categories. Please know that we will use your preferred pronouns despite the fact that we cannot offer addiitonal options for the purposes of this form.
Choose
Female
Male
Race (check all that apply):
*
Hispanic or Latinx
American Indian or Alaska Native
Asian
Black/African-American
Native Hawaiian or Pacific Islander
White
Required
Primary Racial Identification (choose only one):
*
American Indian or Alaska Native
Asian
Black/African-American
Native Hawaiian or Pacific Islander
Hispanic/Latinx
White
Other:
What is your native language?
*
Your answer
Are you an English language learner?
*
Yes
No
Employment Status:
*
Choose
I am employed.
I am employed but recently received a termination notice.
I am unemployed but actively looking for work.
I am not employed and not looking for work at this time.
If employed, what are your average hours per week?
Your answer
If employed, where are you employed?
Your answer
If employed, what is your job title?
Your answer
What is your yearly household income?
*
$0-$9,999
$10,000-$14,999
$15,000-$24,999
$25,000-$34,999
$35,000-$49,999
$50,000-$74,999
$75,000 and above
Unknown
Where did you last attend school?
*
Choose
In the United States
In another country
How many years of school did you complete? (do not include college years).
*
Choose
1 year (U.S. 1st Grade)
2 years (U.S. 2nd Grade)
3 years (U.S. 3rd Grade)
4 years (U.S. 4th Grade)
5 years (U.S. 5th Grade)
6 years (U.S. 6th Grade)
7 years (U.S. 7th Grade)
8 years (U.S. 8th Grade)
9 years (U.S. 9th Grade)
10 years (U.S. 10th Grade)
11 years (U.S. 11th Grade)
12 years (U.S. 12th Grade)
Educational History (choose all that apply to you):
*
I have a United States high school diploma.
I have a United States high school equivalency certificate.
I have a foreign high school diploma or completion certificate.
I have some college course credits but did not complete a college degree.
I have a college or other professional degree.
None of these apply to me.
Required
Do you receive public assistance (e.g. TANF, SNAP, WIC, SSDI, etc.)
*
Yes
No
Do you have any of the following barriers to employment and/or education? (choose all that apply to you):
*
Homeless
Veteran
Single Parent
Registered Sex Offender
Displaced Homemaker
Long-term Unemployed
Individual with a Disability
Migrant/Seasonal Farm Worker
English language learner
Cultural Barriers
Difficulty reading/low literacy skills
Exhausting TANF Within 2 Years
Low Income
Transportation
Lack of Child Care
None of these apply to me
Required
Disability Status:
*
Choose
I do not have a disability.
I have documented disability as defined by ADA.
I choose not to disclose my disability status.
Are there any health concerns we should know about? If so, please list them below.
*
Your answer
Do you have at least one child that attends school in Urbana School District #116?
*
Yes
No
Internet Access: please indicate which statement best applies to you.
*
I have reliable wifi or wired interent access.
I have wifi or wired interent access, but it is not reliable.
I do not have access to wifi or a wired internet connection.
Technology: please indicate the devices you could use for remote learning (check all that apply).
*
I have a smartphone.
I have a tablet.
I have a desktop or laptop computer.
I have none of the above.
Required
Which program are you interested in?
*
High School Diploma
English as a Second Language (ESL)
Pre-CNA
Certified Nursing Assistant (CNA)
Next
Page 1 of 6
Clear form
Never submit passwords through Google Forms.
This form was created inside of Urbana School District 116.
Report Abuse
Forms
