Skip To Main Content

Enrollment Information Form

Submit your information to get started!

Required

NamerequiredStudent first and last name.
First Name
Last Name
Student first and last name.
Please add a complete email address.
Please confirm a complete and matching email address.
Genderrequired
Type your date of birth mm/dd/yyyy and select the date on the calendar. (Must contain a date in MM/DD/YYYY format)
What course are you interested in?requiredPlease select up to 11 choices
Please select up to 11 choices
Are you currently a student at any high school in this state?required
Providing your SSN helps us match records and accurately report program outcomes.
Attach up to 1 file with a maximum size of 10MB
No file chosen
Please include only your head and shoulders in the image.
Are you a U.S. Citizen?requiredWe accept ALL students, regardless of whether you choose YES or NO.
We accept ALL students, regardless of whether you choose YES or NO.
Please select the statement that describes you.
Ethnicity:NOTE: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race, refers to Hispanic ethnicity.required
Name of Emergency ContactrequiredWho can we contact if we cannot reach you?
First Name
Last Name
Who can we contact if we cannot reach you?
Employment Information: requiredChoose the statement that best describes your employment status.
Choose the statement that best describes your employment status.
Please select the highest educational status you have achieved.
Please type the name of the last school you attended.
Previous Schooling LocationrequiredWhere did you complete most of your previous education?
Where did you complete most of your previous education?
School Attendance Status at Entry:requiredSelect the option that BEST describes your current school situation:
Select the option that BEST describes your current school situation:
Please select the statement that best describes how you first learned about our program.
DEMOGRAPHICS: Do you have any physical, mental, or learning impairments?required
Have you ever had an IEP or 504 in the past? Sometimes students who struggle in school are given a document called the IEP (Individual Educational Plan) or a 504 that allows for accommodations such as extra time or use of a calculator to complete academic assignments, quizzes, or tests.required
Do you currently have an IEP or 504required
Do you live in an urban area (inside city)?required
Do you live in a rural area (outside city)?required
Do you currently receive public assistance? Organizations such as Temporary Assistance for Need Families (TANF), SNAP (food stamps), SSI, and WIC are examples of public assistance.required
Do you have a low level income?required
Are you currently enrolled in SNAP (Food Stamps) program?required
Are you currently enrolled in a TANF (Temporary Assistance for Needy Families) program?required
Are you a displaced homemaker? A YES response means you were previously a stay-at-home mom or dad, but you are now seeking work due to a change in your household situation.required
Are you a single parent?required
Are you a parent of a child under the age of 5?required
Are you a dislocated worker? A YES response means that you were laid off or lost your job due to the company moving away.required
Are you a dependent yourself, or do you claim to have dependent(s) yourself? A YES response means that either someone claims you as a dependent OR you claim to have dependent(s) yourself.required
Are you currently, or have you ever, been in foster care?required
Are you considered to be homeless, or are you a runaway? A YES response means that you DO NOT have a permanent, regular nighttime residence (other than a vehicle, a shelter, or temporarily staying with a friend).required
Do you speak a language other than English at home?required
We understand that there are some circumstances that make it difficult to come to school or get a job. We have many resources that can help you with those difficulties. Please select any of the statements listed below that apply to you, because we may be able to help you!requiredSelect all statements that apply to you.
Select all statements that apply to you.
Are you a migrant/seasonal farm worker?requiredPlease select the statement that best describes you.
Please select the statement that best describes you.
Are you an active military member?requiredPlease select the statement that best describes you.
Please select the statement that best describes you.
Are you involved in a Vocational Rehabilitation agency?requiredIf you don't recognize any of these choices, select NO or UNKNOWN.
If you don't recognize any of these choices, select NO or UNKNOWN.
Do you utilize Wagner Peyser Employment services?requiredWagner-Peyser is a federally-funded Unemployment Service, which connects employers with job seekers.
Wagner-Peyser is a federally-funded Unemployment Service, which connects employers with job seekers.
Ex-Offender: Have you ever been convicted of a crime?required
Cultural Barriers to Employment:requiredDo you have any cultural barriers that affect your job opportunities?
Do you have any cultural barriers that affect your job opportunities?
Student Goals: requiredPlease select the goals you would like to accomplish with us.
Please select the goals you would like to accomplish with us.
0 / 1000

Release of Information

I am enrolling in an Adult Basic Education (ABE) program. This ABE program works with the following programs and agencies to help students improve their skills and earn better jobs:

  • Other state-funded adult education programs
  • WorkOne offices and job training programs
  • Public and private colleges
  • State executive offices, departments, and agencies including the Indiana Department of Workforce Development (IDWD), Division of Adult Education and the Indiana Department of Education.

By signing below, I understand and agree to the following:

  • The information on my intake form is correct.
  • DWD use of directory information (name, address, birth, and social security number) to match test score records, wage information, and college/training program enrollment records that assist the state to evaluate and improve its programs and to report results to the federal and state government.
  • The sharing of information between the agencies and programs listed above. This information may include my name, enrollment information, education/career goals, test scores, HiSET or GED exam information, and employment history. The information will be kept strictly confidential and will be used for program administration, research, and evaluation purposes.
Consent to Release of Informationrequired

Photo Release

We love to celebrate success with our students, and we often do that through pictures, articles, slideshows, and other fun media. In order for you to participate in that, we will need your permission to use your photo.

I grant Crawfordsville Adult Resource Academy, its representatives and employees the right to take and/or use provided photographs of me in connection with documents and promotional materials published by the same. I authorize Crawfordsville Adult Resource Academy, its representatives and employees, to use and publish the same in print and/or electronically.

I agree that Crawfordsville Adult Resource Academy may use such photographs of me, with or without my name, for purposes including training and instruction manuals, promotional materials, and electronic documents.

Student Photo Release:required
Must contain a date in MM/DD/YYYY format