Adult Education Intake Information - DEV-Lanier Technical College

Previous Student Information

Highest School Grade Attended:

Highest award/degree earned:

Did you attend school in the U.S.A or another country?

U.S.A
Other Country
I have not ever attended school

Labor Status:

--Select One--
Employed Full Time
Employed Part Time
Employed, but I have received a notice of termination, facility closure, or I am a transitioning service member.
Unemployed and looking for work
Not working and not looking for work (Homemaker, retiree, student)

Have you or someone in your household received any of the following in the last six months?

Select All
Temporary Assistance for Needy Families (TANF)
Have you received TANF for more than two years in total?
Supplemental Nutrition Assistance Program (SNAP), “food stamps”
Supplemental Security Income (SSI)
State or local income-based public assistance
None of the above

How many family members, including yourself, have lived in your household in the last six months?

Release of Information

Consent is valid one year from the date the form is signed by the student.

Permission:

Military Personnel
Department of Labor
Court System
Parents or Guardians
Youth Challenge
Other (please explain below)

I give permission for the following to have access to the information in my student folder including attendance records, grades, etc.
Check all that apply.

Other explaination:*

Additional permission:

I give my permission for my name and/or photo to be ncluded in publications (i.e., graduation programs, brochures, etc.)
I will allow my picture on the graduation presentation.
I give my permission to release my official GED test scores to my Adult Education Center.
I give my permission to the test center to release any demographic and test history information to certain indivduals (list names below).

NOTICE: Please consider checking all of these so that we can keep you updated with your scores and be able to send your picture to the newspaper to celebrate your successes!

Names of individuals that you allow the center to release information to.*

List names separated by a comma.

I understand that academic personnel or state officials may have access to student files for program purposes.

I also understand that I may be contacted by state officials to provides follow-up information that may be released for analytical purposes only.

Signature*

Comments

This field is for validation purposes and should be left unchanged.

Step 1 of 2

Previous Student Information

Release of Information

A UNIT OF THE