2 AEL Enrollment Form V2

Texas Educating Adults Management System (TEAMS)

Enrollment Intake Form

Adult Education and Literacy (AEL) providers must collect certain demographic and personal information from individuals seeking AEL services to comply with federal and state requirements. AEL providers staff collecting this information are trained to obtain, maintain, and protect personally identifiable information. Students can request a copy of local privacy policies at any time. This document contains Personally Identifiable Information (PII All entities with access to this document are expected to protect PII as instructed in TWC guidance: WD Letter 02-18 and WD Letter 13-08 at all times.
Unique TEAMS ID Office Use
Enrollment Date

MonthDayYear
Date
Last Name*
First Name*
Middle Initial
Do you have a Social Security Number?*
Enter your Social Security Number (Numbers Only)*
SSN Collection Date*

MonthDayYear
Date
SSN Did not disclose*

SSN Did not disclose
Recorded by
Type of ID being provided*
Eligibility Verification Document Provided*
Are you providing a Drivers License or state ID?*
Which U.S. state is your Drivers License or ID from?*
Did you provide a REAL ID? Must have a star (Examples above)*
Drivers License or ID Number*
DL/ID Collection Date*

MonthDayYear
Date
No REAL ID*

No REAL DL/ID disclosed
Recorded by
Identify Document Name*
Doc Number*
Expiration Date of Submitted ID*

MonthDayYear
Date
Has Identity Document been Uploaded*

YesNo
Has Identity Document been Uploaded
Date of Birth*

MonthDayYear
Date
Age*
Gender
Gender*

MaleFemale
Ethnicity
Ethnicity

Yes (Hispanic/Latino)No (Hispanic/Latino)
Race (Check all that apply)*

American Indian or Alaska NativeAsianBlack/African AmericanNative Hawaiian or Other Pacific IslanderWhite
Street Address*
City*
Zip Code*
Mobile Phone*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Email*
example@example.com
Additional Comments
Do you have a disability?
Do you have a disability?*

NoYesDo not disclose
Category of Disability (Check all that apply)*

The impairment is primarily physical, due to a chronic health condition.The impairment is primarily physical, including mobility.Because of mental illness, psychiatric disability, or emotional condition, the participant has serious difficulty concentrating, remembering, or making decisions.The participant is blind or has serious difficulty seeing.The participant is blind or has serious difficulty hearing.The participant has a learning disability.The participant has a cognitive or intellectual disability.Participant does not wish to disclose his/her category of disability.
Are you a Veteran?
Are you a Veteran?*

NoYesStatus not known
Eligible for Veteran Status
Eligible Veteran Status*

Yes, <=180 daysYes, Eligible VeteranYes, Other Eligible PersonNo
Disabled Veteran?*
Disabled Veteran*

YesYes, special disabledNo
Is your spouse a Veteran?*

NoYes
Is your spouse a Veteran?*
Date of Actual Military Separation*

MonthDayYear
Date
Employment Status at Program Entry*
Employment Status at Program Entry*

EmployedEmployed, but Received Notice of termination of Employment/ Military Separation is pendingNot in labor forceUnemployed
Employer Name*
Employment city, state*
Long-Term Unemployed at Program Entry*
Long-Term Unemployed at Program Entry*

Yes, Unemployed 27 weeks or moreNo
Hours Employed per Week*
Reason for not looking for work*
Reason for not looking for work*

Full-time caregiver/parentDisabledIncarceratedIneligible to workDependentInstitutionalizedOther
Other reason not looking for work*
Type of Community*
Type of Community*

Urban - CityRural - Countryside
Current School Status*
School Status at Program Entry*

Currently in-school, Postseconday School (College/University)Secondary School DropoutSecondary school graduate or has a recognized equivalentWithin age of compulsory school attendance
Highest School Grade Completed*
Highest Education Level Completed*
Highest Education Level Completed*

Attained a secondary school diplomaAttained a secondary school equivalencyAttained a postsecondary technical or vocational certificate (non-degree)Completed one or more years of postsecondary educationAttained an Associate’s degree (2 years of College/University )Attained a Bachelor’s degree or higher (4 or more years of College/University )Certificate of attendance/completion as a result of successfully completing an Individualized Education Program (IEP)No educational level was completed
Location of Highest level completed*
Location of Highest Level Completed

In the USOutside the US
Migrant and Seasonal Farmworker Status*
Migrant and Seasonal Farmworker Status*

NoSeasonal FarmworkerMigrant FarmworkerMigrant and Seasonal Farmworker YouthDependent AdultType Dependent Youth
On Public Assistance (WIC, CHIP, TANF, SNAP, etc.)*
On Public Assistance (WIC, CHIP, TANF, SNAP, etc.)*

NoYesDo not disclose
Expanded Eligibility for TANF*
Expanded Eligibility for TANF*

YesNoNot Applicable
Exhausting TANF within 2 years*
Exhausting TANF within 2 years*

YesNoNot Applicable
Are you a Foster Care Youth?*
Are you a Foster Care Youth?*

NoYes
Are you Homeless?*
Are you Homeless?*

NoYes
Are you Low-Income status?*
Are you Low-Income Status?

NoYes
Are you an English Language Learner?*

NoYes
Are you an English Language Learner?*
Do you have any cultural barriers?*
Do you have any cultural barriers?*

NoYes
Immigrant (Were you born outside the U.S.?)*
Immigrant (Were you born outside the U.S.?)

NoYes
Displaced Homemaker*
Are you a displaced homemaker?*

NoYes
Are you a single parent?*
Are you a single parent?*

NoYesDo not disclose
Do you have children 18 and younger?*
Do you have children that are 18 years or younger?*

NoYes
Parent of Child(ren) ages 0-5*
Parent of Child(ren) ages 0-5*

YesNo
Parent of Child(ren) ages 6-10*
Parent of Child(ren) ages 6-10*

YesNo
Parent of Child(ren) ages 11-13*
Parent of Child(ren) ages 11-13*

YesNo
Parent of Child(ren) ages 14-18*
Parent of Child(ren) ages 14-18*

YesNo
Ex-Offender Status*
Ex-Offender Status*

NoYesNot Applicable
Date released from Incarceration*

MonthDayYear
Date
WIOA Adult*
WIOA Adult*

NoYes, Local FormulaYes, StatewideYes, Both Local Formula and StatewideReportable Individual
WIOA Dislocated Worker*
WIOA Dislocated Worker*

NoYes, Local FormulaYes, StatewideYes, Both Local Formula and StatewideReportable Individual
WIOA Youth*
WIOA Youth*

NoYes, Local FormulaYes, StatewideYes, Both Local Formula and StatewideReportable Individual
WIOA Job Corps*
WIOA Job Corps*

NoUnknownYesReportable Individual
WIOA Vocational Rehabilitation*

NoYesVR&EBoth VR and VR&EUnknown
WIOA Wagner-Peyser Employment Service*

NoYes, Local FormulaReportable Individual
WIOA Vocational Rehabilitation*
WIOA Wagner-Peyser Employment Services*
WIOA YouthBuild Grant Number
In Correctional Facility*
In Community Corrections*
On Parole*
Other Institutionalized Setting*
On Probation (Community Supervision)*
Family Literacy Participant*
In Workplace Literacy Program(s)*
Are you in a Correctional Facility?*

NoYes
In Community Corrections?*

NoYes
On Parole?*

NoYes
Other Institutionalized Setting?*

NoYes
On Probation (Community Supervision)?*

NoYes
Family Literacy Participant*

NoYes
In Workplace Literacy Program(s)*

NoYes
Participant in Job & Training Program*

NoYes
Referred by a One-Stop Center?*

NoYes
Referred by TANF?*

NoYes
Referred by a College?

NoYes
Participant in Job & Training Program*
Were you referred by a One-Stop Center?*
Were you referred by TANF?*
Were you referred by a College?*
The information provided is complete and correct to the best of my knowledge. I agree to abide by Adult Education Program policies, rules and regulations. I further understand the submission of false information is grounds for rejection of my application, withdrawal of acceptance, and cancellation of enrollment. My signature below shall constitute acknowledgement to statistical use of my records of enrollment, progress, credential obtainment, and transition to postsecondary enrollment or employment. My signature below also authorizes use of my personally identifiable information, including my employment and wage information pre, during and post- enrollment for audit, study and evaluation of the Adult Education and Literacy program performance and other state and federally- funded programs.

Such programs may include but are not limited to those under the laws administered by the Texas Education Agency and the Texas Higher Education Coordinating Board.

I acknowledge that the Adult Education and Literacy program and that TWC may release personal identifiable information to other local, state, federal, partners and/or stakeholders for verification of state and federal program requirements, performance reporting, audit, evaluation, study and to monitor the programs performance.

Participants who are 17 and 18 years of age must have written parental permission or qualify for another exemption from compulsory attendance law. Additional information may be found at: TWC Website Privacy & Security Information
Upload Front of ID*

Cancelof
Upload Back of ID*

Cancelof
Participant Signature*
Date*

MonthDayYear
Date
Are you 18 years old or under?*
ParentGuardian Signature*
Date*

MonthDayYear
Date
Should be Empty: