Registration *2022-23 Adult Education and Literacy Student Enrollment Form OCC Adult Learning Center Student IDHiddenDate Submitted: MM slash DD slash YYYY Name:(Required)Please carefully type your legal name as it appears on your ID. First Middle Last 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) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age: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 No Do you need accommodation(s) for your disability?(Required)If you select Yes, please inform your teacher of what accommodations you need. Yes No *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 No 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 ENROLLMENTAre 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. I have a physical or mental impairment that substantially limits one or more major life activities. I am a stay-at-home mom or dad who needs to return to the workforce. My ability to compete in business has been impaired due to lack of credit opportunities. My unemployment benefits have lasted for 27 continuous weeks or more. I do not have a fixed, regular, and adequate nighttime residence, or I sleep in a shelter designated for temporary living accommodations, or in places not designated for human habitation. I am in the foster care system. My employment is in seasonal agriculture, and I must move away from my permanent residence for farm work. I am employed in temporary farm work, but I do not have to move away from my permanent residence to seek farm work. I have been sentenced to a term of probation by a Federal or State court, or I have been released from a Federal, State, or local correctional institution. I have been enrolled in Temporary Assistance for Needy Families (TANF) for 3 or more years. I am a parent or guardian raising a child or children alone, without a partner. None of these apply Highest Degree or Level of School Completed(Required)Please check the highest level of education you have completed. No schooling Grades 1-5 Grades 6-8 Grades 9-12 (no diploma) High School Diploma High School Diploma or alternate credential (GED) High School Diploma or alternate credential (TASC) High School Diploma or alternate credential (HiSET) Some college, no degree College or professional degree Unknown 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 upMax. 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 No Country of Birth:(Required)Select one:UNITED STATESAFGHANISTANALAND ISLANDSALBANIAALGERIAAMERICAN SAMOAANDORRAANGOLAANGUILLAANTARCTICAANTIGUA AND BARBUDAARGENTINAARMENIAARUBAAUSTRALIAAUSTRIAAZERBAIJANBAHAMASBAHRAINBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBENINBERMUDABHUTANBOLIVIA, PLURINATIONAL STATE OFBONAIRE, SINT EUSTATIUS AND SABABOSNIA AND HERZEGOVINABOTSWANABOUVET ISLANDBRAZILBRITISH INDIAN OCEAN TERRITORYBRUNEI DARUSSALAMBULGARIABURKINA FASOBURUNDICAMBODIACAMEROONCANADACAPE VERDECAYMAN ISLANDSCENTRAL AFRICAN REPUBLICCHADCHILECHINACHRISTMAS ISLANDCOCOS (KEELING) ISLANDSCOLOMBIACOMOROSCONGOCONGO, THE DEMOCRATIC REPUBLIC OF THECOOK ISLANDSCOSTA RICACOTE D'IVOIRE (IVORY COAST)CROATIACUBACURACAOCYPRUSCZECH REPUBLICDENMARKDJIBOUTIDOMINICADOMINICAN REPUBLICECUADOREGYPTEL SALVADOREQUATORIAL GUINEAERITREAESTONIAETHIOPIAFALKLAND ISLANDS (MALVINAS)FAROE ISLANDSFIJIFINLANDFRANCEFRENCH GUIANAFRENCH POLYNESIAFRENCH SOUTHERN TERRITORIESGABONGAMBIAGEORGIAGERMANYGHANAGIBRALTARGREECEGREENLANDGRENADAGUADELOUPEGUAMGUATEMALAGUERNSEYGUINEAGUINEA-BISSAUGUYANAHAITIHEARD ISLAND AND MCDONALD ISLANDSHOLY SEE (VATICAN CITY STATE)HONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRAN, ISLAMIC REPUBLIC OFIRAQIRELANDISLE OF MANISRAELITALYJAMAICAJAPANJERSEYJORDANKAZAKHSTANKENYAKIRIBATINORTH KOREA (DPRK)SOUTH KOREAKUWAITKYRGYZSTANLAO PEOPLE'S DEMOCRATIC REPUBLICLATVIALEBANONLESOTHOLIBERIALIBYALIECHTENSTEINLITHUANIALUXEMBOURGMACAOMACEDONIA, THE FORMER YUGOSLAV REPUBLIC OFMADAGASCARMALAWIMALAYSIAMALDIVESMALIMALTAMARSHALL ISLANDSMARTINIQUEMAURITANIAMAURITIUSMAYOTTEMEXICOMICRONESIA, FEDERATED STATES OFMOLDOVA, REPUBLIC OFMONACOMONGOLIAMONTENEGROMONTSERRATMOROCCOMOZAMBIQUEMYANMARNAMIBIANAURUNEPALNETHERLANDSNEW CALEDONIANEW ZEALANDNICARAGUANIGERNIGERIANIUENORFOLK ISLANDNORTHERN MARIANA ISLANDSNORWAYOMANPAKISTANPALAUPALESTINIAN TERRITORY, OCCUPIEDPANAMAPAPUA NEW GUINEAPARAGUAYPERUPHILIPPINESPITCAIRNPOLANDPORTUGALPUERTO RICOQATARREUNIONROMANIARUSSIAN FEDERATIONRWANDASAINT BARTHELEMYSAINT HELENA, ASCENSION AND TRISTAN DA CUNHASAINT KITTS AND NEVISSAINT LUCIASAINT MARTIN (FRENCH PART)SAINT PIERRE AND MIQUELONSAINT VINCENT AND THE GRENADINESSAMOASAN MARINOSAO TOME AND PRINCIPESAUDI ARABIASENEGALSERBIASEYCHELLESSIERRA LEONESINGAPORESINT MAARTEN (DUTCH PART)SLOVAKIASLOVENIASOLOMON ISLANDSSOMALIASOUTH AFRICASOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDSSOUTH SUDANSPAINSRI LANKASUDANSURINAMESVALBARD AND JAN MAYENSWAZILANDSWEDENSWITZERLANDSYRIAN ARAB REPUBLICTAIWAN, PROVINCE OF CHINATAJIKISTANTANZANIA, UNITED REPUBLIC OFTHAILANDTIMOR-LESTETOGOTOKELAUTONGATRINIDAD AND TOBAGOTUNISIATURKEYTURKMENISTANTURKS AND CAICOS ISLANDSTUVALUUGANDAUKRAINEUNITED ARAB EMIRATESUNITED KINGDOMUNITED STATES MINOR OUTLYING ISLANDSURUGUAYUZBEKISTANVANUATUVENEZUELA, BOLIVARIAN REPUBLIC OFVIET NAMVIRGIN ISLANDS, BRITISHVIRGIN ISLANDS, U.S.WALLIS AND FUTUNAWESTERN SAHARAYEMENZAMBIAZIMBABWEKOSOVOSCOTLANDVIETNAMYUGOSLAVIAIvory CoastTIBETMAURITANIANORTH MACEDONIACABO VERDEESWATINII speak a language other than English at home.(Required) Yes No What is the language you first learned as a child?(Required)Select one:EnglishAfrikaansAlbanianAmharicArabicArmenianAzerbaijaniBasqueBelarusianBengaliBosnianBulgarianCatalanCebuanoChichewaChineseCorsicanCroatianCzechDanishDariDutchEsperantoEstonianFilipinoFinnishFrenchFrisianGalicianGeorgianGermanGreekGujaratiHaitianHausaHawaiianHebrewHindiHmongHungarianIcelandicIgboIndonesianIrishItalianJapaneseJavaneseKannadaKazakhKhmerKoreanKurdishKyrgyzLaoLatinLatvianLithuanianLuxembourgishMacedonianMalagasyMalayalamMalayMalteseMaoriMarathiMongolianMyanmar/BurmeseNepaliNorwegianPashtoPersianPolishPortuguesePunjabiRomanianRussianSerbianShonaSesothoSindhiSinhalaSlovakSlovenianSamoanScots GaelicSomaliSpanishSundaneseSwahiliSwedishTajikTamilTeluguThaiTurkishUkrainianUrduUzbekVietnameseWelshXhosaYiddishYorubaSTUDENT 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)Select one:referral from a friend or relativeTV or radionewspaperbrochure or flyerGoogle/WebsiteSocial Mediareferral from employerI am a returning studentOtherPlease let us know how you heard about our program? Photo ReleaseWe 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 ConductAdult 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.