Registration Form Personal InformationName* First Initial Last Are you under the age of 18?*YesNoIf you are under the age of 18.We need you to arrive 30 minutes before testing, under-18s and their guardian/parent need to meet with advising to sign paperwork and bring a withdrawal form and a state-issued IDWhich location do you wish to enroll with?LafayetteFrankfortDelphiMonticelloTiptonWhat subject are you interested in?ELLHSE (High School Equivalency)College and Career ReadinessJob TrainingDo you have an F-1 Visa?YesNoIf yes, LARA cannot serve you as you are receiving educational services elsewhere in the U.S.Will you be able to attend class for at least six weeks?YesNoIf no, thank you for your interest, but LARA cannot serve students unable to commit to six weeks of class.Last Four Digits of Social Security Number (If available)Have you studied with LARA before?*YesNoIf yes, when?*Addressplease enter your complete street address. 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Laptop or Desktop Computer Smartphone Tablet Wifi Emailplease enter your email address so we know where to reach you. Enter Email Confirm Email Birthdate* Date Format: MM slash DD slash YYYY GenderMaleFemaleNon-BinaryEmergency Contact Person First Last PhoneTheir Relationship to YouEthnicity*Are you of Hispanic, Latino, or Spanish origin?No, Not of Hispanic, Latino, or Spanish OriginYes, Mexican, Mexican American, ChicanoYes, Puerto RicanYes, CubanYes, an other Hispanic, Latino, or Spanish originRace (Choose one or more)* African American or Black American Indian or Alaskan Native White or Caucasian Chinese Filipino Asian Indian Vietnamese Korean Japanese Other Asian Native Hawaiian Samoan Chamorro Other Pacific Islander Some other race U.S. Citizen*YesNoNational Origin (If not the United States)What is the primary language spoken at home?Educational StatusPrevious School Location In the U.S. Outside the U.S. Current Educational Status* Unknown Did not Graduate High School Diploma Graduated High School Post-Sec High school Diploma or Equivalent Some College College or Professional Degree F1 Visa College or Professional DegreeAssociatesBachelor'sMaster'sPhDField of StudyLast Grade CompletedGrades 1-12Last School AttendedLocation of Last School AttendedEmployment StatusEmployedI am currently employedI am currently employed; looking for new employmentSeeking EmploymentI am able to work and seeking employmentI am able to work but am not currently seeking employmentUnemployed more than 6 monthsI am able to work and have been looking for employment for the last 6 monthsNot in the Labor ForceI am not able to work at this timeEmployer:Start DateTANF EligibilityDo you have, or are you a Dependent?YesNoHousehold InformationNumber of people in your household?Monthly Household Income (Before Taxes)Check all that apply:* Impairments (Physical, Mental, or Learning) Live in an urban area (City) Live in a rural area (area with less than 1000 people. Frankfort and Tipton are Rural.) Receive Public Assistance (TANF, SNAP, WIC) Low Income Displaced Homemaker Single Parent Dislocated Worker Foster Care Youth Homeless/ Runaway Youth Active MilitaryYesNoSpouseVocational RehabilitationYesNoUnknownVR & EBoth VE and VR & EWagner-Peyser EmploymentYesNoUnknownMigrant/Seasonal Farm WorkerNoMigrantMigrant & SeasonalDependentEx-Felony OffenderYesNoUnknownConvicted Sex OffenderYesNoCultural Barriers to EmploymentYesNoUnknownPlease note that all of this information is for our confidential records only. Due to legislation and policy, Adult Education is not permitted to serve students on F-1 Visas. Certain criminal offenders also cannot be served due to legal restrictions. Please sign below:*Agreement*I certify that all the provided information is accurate and complete to the best of my knowledge. I understand that intentionally giving false information could result in the invalidation of my test results and dismissal from LARA. - Check Here
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