Registration – OCCC Adult Education

*2022-23 Adult Education and Literacy Student Enrollment Form

OCC Adult Learning Center

Student ID

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Date Submitted:

Name:(Required)

Please carefully type your legal name as it appears on your ID.

Email:(Required)

Enter an email address you can access easily and check frequently. Please make sure that you only use ONE email account, and that the email account belongs only to you, as shared accounts are not allowed.

Social Security Number:

We do not require you to provide your social security number, but providing it helps us to track your accomplishments as well as any resources we might be able to provide for you. As always, we keep all of our data secure.

Please provide your address below:(Required)

Mobile Phone Number:(Required)

We communicate important messages to students via text message. If you do not currently have a mobile phone, please list a mobile phone number of a trusted family member or friend so that you can receive messages.

Date of Birth:(Required)

Age:

Gender:(Required)

Male

Female

Other

We are unable to serve students who are under 16 years old, so students who are under 16 will not be able to submit this form.

We accept students that are 16 or 17 years of age, but you must bring a completed age wavier/release form with you to your orientation appointment. You can download a copy here or come to OCCC FACE center to pick one up.

Do you have a disability?(Required)

Yes

Do you need accommodation(s) for your disability?(Required)

If you select Yes, please inform your teacher of what accommodations you need.

Yes

*Please inform your teacher of your disability and any accommodations you need.

Name of Emergency Contact:

Who can we contact if we cannot reach you?

First Last

Emergency Contact's Phone Number:

Emergency Contact's Relationship to You:

Have you taken classes with us before?(Required)

Yes

Which program did you attend?(Required)

ESL

ELL

HSE/GED

When did you attend this program?(Required)

Less than a year ago

More than a year ago

ETHNICITY/RACE INFORMATION: REQUIRED FOR ENROLLMENT

Are you Hispanic/Latino?(Required)

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race, refers to Hispanic ethnicity.

No, I am not Hispanic/Latino.

Yes, I am Hispanic/Latino.

Race:(Required)

Please select all that apply.

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South America, including Central America, and who maintains a tribal affiliation or community attachment)

Asian (A person having origins in any of the peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam)

Black or African American (A person having origins in any of the Black racial groups of Africa)

Native Hawaiian or Other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands)

White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa)

Please select the statement(s) that apply to you.

DHS Client/Public Assistance

Live in institutional setting

State Corrections

County or Community Corrections

Employment Status: (Choose the one that best describes you.)(Required)

I am employed full-time.

I am employed part-time.

Unemployed and looking for work.

Unavailable or not looking for work

Barriers: Select the statement(s) below that describes you:(Required)

You may select more than one statement.

My culture at home is different than the mainstream culture.

I am learning the English language.

I do not have a High School diploma.

Please select any of these statements that apply to you.(Required)

Select all that apply.

Highest Degree or Level of School Completed(Required)

Please check the highest level of education you have completed.

Where did you complete most of your education so far?(Required)

US-based (in the US)

Non-US-based (outside of the US)

Please select the WIOA Core Program you received below:(Required)

As an adult learner you may have received workforce and skill training from other Workforce Innovation and Opportunity Act (WIOA) providers in Oklahoma. If you have ever received job-seeker assistance services from your local workforce development center or vocational rehabilitation services from other state-supported providers, please select those below. If not, Select NONE.

Title 1 Adult programs

Title 1 Youth programs

Title 2 Dislocated Worker programs

Title 3 Wagner-Peyser

Title IV Vocational Rehabilitation Services

None

Upload a favorite picture of your that we can use for your profile (optional)

*Include only from the shoulders up

Max. file size: 0 bytes.

Are you a US Citizen?(Required)

We accept ALL students, regardless of which citizenship status you choose. Clicking NO will not prevent you from enrolling with us.

Yes

Country of Birth:(Required)

I speak a language other than English at home.(Required)

Yes

What is the language you first learned as a child?(Required)

STUDENT RESOURCES: We understand that there are some circumstances that make it difficult to come to school or get a job. There are many local 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.(Required)

I am in need of food assistance.

I need help with transportation.

I need help with child care.

I need immigration information.

I would like help with employment or career training.

I don't need any help with these things.

How did you hear about our program?(Required)

Please let us know how you heard about our program?

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 permission to use your photo.

I grant Oklahoma City Community College, 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 Oklahoma City Community College, its representatives and employees, to use and publish the same in print and/or electronically. I agree that Oklahoma City Community College 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)

I agree to the above photo release statement.

I do not agree to the above photo release statement.

Student Contract/Code of Conduct

Adult Student Conduct Form - Adult Education and Literacy Classes - Scroll to read the conduct expectations .(Required)

The Oklahoma City Community College Adult Learning Center (ALC) endorses and encourages the development
of adult learning opportunities available in the Adult Basic Education Classes. Our goals for the program are:
(1) to provide quality education, and (2) to provide an environment conducive to learning. To be able to meet
these goals, certain expectations are required of all adult students, including those who are under 18 years of age
and who have been approved to attend ABE classes.

The following guidelines and rules of conduct, both for the classroom and the building premises, are simple,
commonly accepted, and above all, designed to create the best possible learning atmosphere for you, the student.

Unacceptable conduct includes (but is not limited to) the following:
• Cheating or plagiarism.
• Excessive loud talking or other disturbing behavior which, in the opinion of the teacher, is a problem for
other students.
• Theft.
• Fighting.
• Arguing with the teacher or other class members.
• Making a social hour out of class time to the point of distracting others who want to study.
• Disrespect for a teacher or other class members.
• Obscene language or gestures.
• Bringing any weapon, alcohol, or drugs onto the building premises.
• Arriving at class with obvious display of intoxication (alcohol or drugs).
• Smoking in places other than the designated smoking areas.
• Racial insults, slurs, or insinuations toward students, teachers, or ALC staff.
• Inappropriate attire.
• Falsification of information on the enrollment form, sign-in sheet, and/or DHS time sheets.
• Any other behavior which the instructor or administration deems unacceptable to a learning environment.

A student’s class membership may be terminated after one infraction notice (verbal or written), indicating
violation of one of the above-stated guidelines, or any other conduct detrimental to a positive learning
environment. Such notice will constitute a one-time-only warning.

Click here to download a copy of the student conduct form.

I, the student, agree to abide by the above-stated policies.

PLEASE SIGN: I authorize Oklahoma Department of Career and Technology Education to release my social security number, assessment results, or other collected data for education or employment research and/or reporting purposes as long as my identity is never revealed.(Required)

This signature acknowledges that the information provided in this form is correct.

Parent/Guardian Signature(Required)

Parent/Guardian, this signature acknowledges that the information provided in this form is correct.