Register – ACCEL College & Career Readiness Program

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ACCEL Student Registration Form

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Name*
First Middle Last
I am enrolling in the following program:*
- ELL (English Language Learning) classes - I need to learn English.
- HSE (High School Equivalency) classes - I need a High School Equivalency
- Latino Leadership Academy
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Student ID
Which location are you interested in attending classes?*
- Carson City
- Fallon
- Fernley
- Online
Which location are you interested in attending classes?*
- Carson City
- Fallon
- Online
Date of Birth*
Age*
Students ages 16 and 17 years old may enroll, but must provide a letter of withdrawal from the last school attended and signed, parental consent prior to enrollment.
Gender:*
- Male
- Female
The government grant that funds our program requires us to collect this information, and only provides us with the options 'male' or 'female.' For purposes of this question, please select the option that matches any government records you may have, such as your driver's license or ID card issued by the state, passport, or permanent resident card. When you meet with your advisor, test proctor and/or teacher, please share your preferred pronouns, and we will be sure to use them.
Primary Language*
Ethnicity/Race*
Choose one or more.
- Amer. Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Pac. Islander
- White
- Hispanic/Latino
Last full grade completed*
- Never attended school
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12 - No Diploma
- HSE (GED, HiSET)
- High School Diploma
- Some College
- College Degree or Professional Degree
Where?*
- U.S. Based Schooling
- Non U.S. Based Schooling
Are you employed?*
- Yes
- Not Looking for Work
- Looking for Work
How many hours do you work per week?*
Company Name*
Position*
How much do you make per hour?*

Student Status*
Check all that apply.
- Cultural Barriers to Employment
- Individual with Disabilities
- Displaced Homemaker
- English Language Learner
- Low Income
- Ex Offender
- Exhausting TANF
- Foster Care Youth
- Homeless
- Long Term Unemployed
- Migrant/Seasonal Farmworker
- Single Parent or Guardian
- None of the Above
Please indicate the type of disability:*
- Physical Disability
- Emotional Disability
- Sensory Disability
- Learning Disability
Cultural Barriers - If the participant perceives him or herself as possessing attitudes, beliefs, customs or practices that influence a way of thinking, acting or working that may serve as a hindrance to employment
Individual with disabilities - The participant indicates that he or she has any disability, defined as physical or mental impairment that substantially limits one or more of the person's major life activities, as defined under the Americans with Disabilities Act of 1990.
Displaced homemaker - The participant has been providing unpaid services to family members in the home and (a) has been independent on the income of another family member but is no longer supported by that income; (b) is the dependent spouse of a member of the armed forces on active duty whose family income is significantly reduced because of (i) a deployment or a call or order to active duty pursuant to a provision of the law, (ii) a permanent change of station, or (iii) the service-connected death or disability of the member; and (c) is unemployed or underemployed and is experiencing difficulty in obtaining or upgrading employment.
English Language Learner - The participant is a person who has limited ability in speaking, reading, writing or understanding the English language and also meets at least one of the following two conditions (a) his or her native language is a language other than English, or (b) he or she lives in a family or community environment where a language other than English is the dominant language.
Exhausting TANF - The participant is within 2 years of exhausting lifetime eligibility under Part A of Title IV of the Social Security Act (42 U.S.C. 601 et seq.), regardless of whether he or she is receiving the befits at program entry.
Ex-offender - The participant is a person who either (a) has been subject to any stage of the criminal justice process for committing a status offense or delinquent act, or (b) requires assistance in overcoming barriers to employment resulting from a record of arrest or conviction.
Homeless - The participant lacks a fixed, regular, and adequate nighttime residence; has a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings; is a migratory child who in the preceding 36 months was required to move from one school district to another due to changes in the parent's or parent's spouse's season employment in agriculture, dairy, or fishing work; or is under 18 years of age and absents himself or herself from home or a place of legal residence without the permission of his or her family (i.e., runaway youth). However, a participant who may be sleeping in a temporary accommodation while away from home should not, as a result of that fact alone, be recorded as homeless.
Long-term unemployed - The participant has been unemployed for 27 or more consecutive weeks.
Low income - The participant (a) receives, or in the 6 months prior to application to the program has received, or is a member of a family that is receiving in the past 6 months assistance through the Supplemental Nutrition Assistance Program (SNAP), the TANF program, the Supplemental Security Insurance (SSI) program, or State or local income-based public assistance; (b) is in a family with total family income that does not exceed the higher of the poverty line or 70% of the lower living standard income level; (c) is a youth who receives, or is eligible to receive, a free or reduced lunch; (d) is a foster child on behalf of whom State or local government payments are made; (e) is a participant with a disability whose own income is the poverty line but who is a member of a family whose income does not meet this requirement; (f) is a homeless participant or homeless child or youth or runaway youth; or (g) is a youth living in a high-poverty area.
Migrant farmworker - The participant is a low-income individual who for 12 consecutive months out of the 24 months prior to application for the program involved has been primarily employed in agriculture or fish farming labor that is characterized by chronic unemployment or underemployment, and faces multiple barriers to economic self-sufficiency.
Single Parent - The participant is a single, separated, divorced , or widowed individual who has primary responsibility for one or more dependent children under age 18 (including single pregnant women).
Youth in foster care - The participant is a person who is currently in foster care or has aged out of the foster care system.
Please list needed accommodations:*
Address*
Street Address City State ZIP Code
Mobile Phone*
Home Phone
Email*
Emergency Contact Name*
Emergency Contact Relationship
- Spouse
- Parent
- Sibling
- Relative
- Friend
- Son/Daughter
- Co-Worker
- Other
Emergency Contact Phone*

Why are you Enrolling?
- Learn English
- Prepare for the GED or HiSET
- Prepare for College
- Train for a Career
What is your Career Path or Goal?*
Are you interested in any of the following career training programs?*
- Medical Billing and Coding
- Pharmacy Technician
- Hospitality, Food Service, and Customer Service
- Medical Assisting
- Paralegal
- I am not interested at this time.
Are you interested in any of the following WNC degree/certification programs?*
- Machine Tool Technology
- Construction Management
- Welding
- Automotive Mechanics
- CNA
- Phlebotomy
- EMS
- I am not interested at this time
- Other
What type of program are you interested in?*
Do you have:*
(Choose all that apply)
- Internet
- Computer
- Smart Phone
- Reliable Transportation
How did you find out about our program?*
- Employer
- Family or Friend
- I attended before
- Newspaper/Radio/Television ad
- Brochure/Flyer
- Department of Employment Training and Rehabilitation/Join/Job Connect
- Court/Corrections/Probation Officer
- Agency Website
- Other
What other way did you find out about our program?*
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Class
Hidden
Class
Hidden
Class
Hidden
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Hidden
Code of Conduct*
I agree to the code of conduct.
ACCEL College and Career Readiness is a caring learning community which respects the right of each individual student to have a safe, enjoyable, and successful learning experience. As members of an extended college community at Western Nevada College, all students are reminded that we must abide by college policies and expectations, including those relating to: equality, diversity, health, and safety.
• Attendance: Students must attend class sessions regularly, exhibit good conduct, and complete all required class work. ACCEL is financed by federal funds based on student enrollment, participation, and completion of classes and programs. Therefore, students must agree to be in regular attendance to ensure continuation of the class. Attendance is required at the first class session or the student may be dropped. Classes with below ten students are subject to reduced hours or cancellation. Individual students may be dropped from the class due to low attendance.
• Children in class: Children are not permitted in class without prior authorization from the Director. Students are asked to make arrangements for childcare.
• Tobacco: Western Nevada College is a tobacco-free campus. All tobacco products including cigarettes, vapes, and chewing tobacco are prohibited anywhere on campus.
Consent Form*
I consent to the following.
1. Consent to the release of information from my student record for the purposes of statistical reports. I understand that this information is to assist the Nevada Department of Education in obtaining and reporting information concerning employment and education gains as required by federal legislation and regulations.

I understand that the student record includes my social security number, which may be shared by the Nevada Department of Education with any of the following entities:

• Nevada Department of Employment Training and Rehabilitation

• Nevada System of Higher Education

• An official High School Equivalency (HSE) scoring site

I understand that reports based on this information will contain statistics about follow-up measures for adult education students in Nevada, and that NO specific or personal information about me will appear in these reports.

2. I authorize the use of my image or likeness, and displayable work products by Western Nevada College on media including but not limited to, WNC website and
social media channels, bulletin boards, newsletters, and press releases.
I authorize the release of my records to the following people and/or agencies:
Type Your Name Verifying Your Agreement with the Above Statements.*
(Parental Consent)Type Your Name Verifying Your Agreement with the Above Statements.*
Student's Social Security number or ITIN:
Your personal information is kept secure and is not shared or used for any other reason than to improve adult education programs. Your social security number helps us track your individual employment and wage record and compile required reports for our grants. You will not be excluded from receiving services if you do not provide a SSN or TITN.

ACCEL College & Career Readiness Program

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