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7<title>Adult Education Enrollment Form | Wallingford Adult Education</title>
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37    <style type="text/css">
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48        toggleEducation();
49        toggleHearAboutUs();
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51        $("input[name='education']").change(toggleEducation);
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109    }
110</script>
110
111
112</head>
113<body class="interior">
114
115
116<header>
117	<a id="skipNavigation" href="#main" tabindex="0">Skip Navigation</a>
118	<a href="/" id="brand"><img src="/images/logo.svg" alt="Logo for: Wallingford Adult Education" /></a>
119
120	<div id="navContainer">
121		<button class="menu toggleNav" aria-controls="navContainer" aria-expanded="false"><span>&times;</span> Close Menu</button>
122		<nav id="mainnav" aria-label="Main">
123			<ul><li class="on menu-item-has-children"><a href="/academic-programs/" target="_self" class="Menu">Academic Programs</a><button aria-controls="academic-programs-dropdown" aria-expanded="false"><span class="sr-only">Toggle submenu for Academic Programs</span></button><div id="academic-programs-dropdown"><ul><li class="on"><a href="/adult-education-enrollment-form/" target="_self">Adult Education Enrollment Form</a></li><li><a href="/academic-programs/adult-basic-education/" target="_self">Adult Basic Education (ABE)</a></li><li><a href="/academic-programs/english-as-a-second-language/" target="_self">English as a Second Language (ESL)</a></li><li><a href="/academic-programs/family-literacy/" target="_self">Family Literacy</a></li><li><a href="/academic-programs/citizenship/" target="_self">Citizenship</a></li><li><a href="/academic-programs/high-school-credit-diploma-program/" target="_self">High School Credit Diploma Program (CDP)</a></li><li><a href="/academic-programs/national-external-diploma-program/" target="_self">National External Diploma Program (NEDP)</a></li><li><a href="/academic-programs/ged-preparation/" target="_self">GED Preparation</a></li><li><a href="/academic-programs/eat-around-the-world/" target="_self">ESL - Eat Around the World</a></li></ul></div></li><li><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/?Division=Medical%20Programs" target="_self" class="Menu">Medical Programs</a></li><li class="menu-item-has-children"><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/?Division=Wallingford" target="_self" class="Menu">Enrichment Programs</a><button aria-controls="enrichment-programs-dropdown" aria-expanded="false"><span class="sr-only">Toggle submenu for Enrichment Programs</span></button><div id="enrichment-programs-dropdown"><ul><li><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/CategoryView.asp?ID=750">Creative Arts</a></li><li><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/CategoryView.asp?ID=754">Health & Wellness</a></li><li><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/CategoryView.asp?ID=751">Money Matters</a></li><li><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/CategoryView.asp?ID=752">Personal Enrichment</a></li><li><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/CategoryView.asp?ID=753">Specialty Classes</a></li><li><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/CategoryView.asp?ID=755">Travel</a></li><li><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/CategoryView.asp?ID=756">Cooking</a></li><li><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/CategoryView.asp?ID=757">ed2go</a></li><li><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/CategoryView.asp?ID=758">Languages</a></li><li><a href="https://enrichment.wallingfordadulted.org/CourseCatalog/?Division=Medical%20Programs">Medical Career Programs</a></li></ul></div></li><li class="menu-item-has-children"><a href="/contact-form/" target="_self" class="Menu">Contact</a><button aria-controls="contact-dropdown" aria-expanded="false"><span class="sr-only">Toggle submenu for Contact</span></button><div id="contact-dropdown"><ul><li><a href="/contact-form/teach-with-us/" target="_self">Teach With Us</a></li><li><a href="/contact-medical-career-programs-coordinator/" target="_self">Contact Medical Career Programs Coordinator</a></li><li><a href="/driving-directions/" target="_self">Locations & Directions</a></li><li><a href="/contact-form/transcript-request-form/" target="_self">Transcript Request Form</a></li></ul></div></li></ul>
124		</nav>
125		<nav id="ancillary" aria-label="Ancillary">
126			<ul><li><a href="/about/" target="_self">About</a></li><li class='search-li'><a id='search-button' class="search-toggle" href='#'>Search</a></li></ul>
127			<form id="search-form" class="search" action="/Search/" method="get">
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129					<input id="search-terms" type="text" name="s" placeholder="Search" required data-container=".search-error" />
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141	</nav>
142	
143</header>
144
145
146<main id="main" class="interior">
147  <div class="wrap">
148    <div id="content" class="content">
149	
150		<h1>Adult Education Enrollment Form</h1>
151	
152    <!-- cms start -->
153    
154
155
156<div style="clear:both"></div>
157<hr />
158
159
160
161<form id="StudentInfoForm" class="ContactForm" action="/adult-education-enrollment-form/default.aspx" method="post">
162  <input type="hidden" name="FormAction" value="Submit Form" />
163  <h2>Please fill out the form: <em class="text">(<span style="color:#ff0000">*</span> denotes required fields)</em></h2>
164
165  <table role="presentation" cellspacing="0" cellpadding="0" class="formTable">
166    <col width="50%">
167    <col width="50%">
168
169    <tr>
170      <td colspan="2">
171        <fieldset id="student-type" class="no-border" data-required="true" data-container=".student-type-error">
172          <legend>Student Type: <span style="color:#ff0000">*</span></legend>
173          <div class="student-type-error"></div>
174          <div><input type="radio" required name="studentType" id="returningStudent" value="Returning Student" /><label for="returningStudent">Returning Student</label></div>
175          <div><input type="radio" required name="studentType" id="newStudent" value="New Student" /><label for="newStudent">New Student</label></div>
176        </fieldset>
177      </td>
178    </tr>
179
180    <tr>
181      <td>
182        <label for="intake-date">Intake Date</label>
183        <input id="intake-date" type="date" name="intakeDate" value="2026-10-04" />
184      </td>
185
186      <td>
187        <label for="social-security-number">SSN</label>
188        <input id="social-security-number" type="text" name="ssn" maxlength="9" aria-describedby="ssn-format" />
189        <span class="sr-only" id="ssn-format">max length 9 characters</span>
190      </td>
191    </tr>
192
193
194    <tr>
195      <td>
196        <label for="last-name">Last Name <span style="color:#ff0000">*</span></label>
197        <input id="last-name" type="text" required name="lastName" autocomplete="family-name" />
198      </td>
199      <td>
200        <label for="first-name">First Name <span style="color:#ff0000">*</span> (as it appears on your ID)</label>
201        <input id="first-name" type="text" required name="firstName" name="given-name" />
202      </td>
203    </tr>
204
205    <tr>
206      <td>
207        <label for="middle-name">Middle Name</label>
208        <input id="middle-name" type="text" name="middleName" name="middle-name" />
209      </td>
210      <td>
211        <label for="suffix">Suffix</label>
212        <input id="suffix" type="text" name="suffix" name="honorific-suffix" />
213      </td>
214    </tr>
215
216    <tr>
217      <td>
218        <label for="preferred-name">Preferred Name</label>
219        <input id="preferred-name" type="text" name="preferredName" maxlength="250" />
220      </td>
221      <td></td>
222    </tr>
223
224  </table>
225
226
227  <hr>
228
229
230  <table role="presentation" cellspacing="0" cellpadding="0" class="formTable">
231    <col width="50%">
232    <col width="50%">
233
234    <tr>
235      <td>
236        <fieldset id="program" class="no-border" data-required="true" data-container=".program-error">
237          <legend>Program <span style="color:#ff0000">*</span></legend>
238          <div class="program-error"></div>
239          <div><input type="checkbox" name="program" id="ged" value="GED" required /><label for="ged">General Educational Development</label></div>
240          <div><input type="checkbox" name="program" id="cdp" value="CDP" required /><label for="cdp">Credit Diploma Program</label></div>
241          <div><input type="checkbox" name="program" id="nedp" value="NEDP" required /><label for="nedp">National External Diploma Program</label></div>
242          <div><input type="checkbox" name="program" id="esl" value="ESL" required /><label for="esl">English As A Second Language</label></div>
243          <div><input type="checkbox" name="program" id="ESLSCOW" value="ESL SCOW" required /><label for="ESLSCOW">ESL SCOW</label></div>
244          <div><input type="checkbox" name="program" id="ESLCheshire" value="ESL Cheshire" required /><label for="ESLCheshire">ESL Cheshire</label></div>
245          <div><input type="checkbox" name="program" id="citizenship" value="Citizenship" required /><label for="citizenship">Americanization/Citizenship</label></div>
246          <div><input type="checkbox" name="program" id="adultBasicEducation" value="Adult Basic Education" required /><label for="adultBasicEducation">Adult Basic Education</label></div>
247          <div>
247<input type="checkbox" name="program" id="eatAroundTheWorld" value="Eat Around The World Class" required /><label for="eatAroundTheWorld">Eat Around The World Class</label></div>
248          <div><input type="checkbox" name="program" id="familyLiteracy" value="Family Literacy Class" required /><label for="familyLiteracy">Family Literacy Class</label></div>
249        </fieldset>
250      </td>
251
252      <td>
253        <fieldset id="class-time" class="no-border" data-required="true" data-container=".class-time-error">
254          <legend>Preferred Class Time <span style="color:#ff0000">*</span></legend>
255          <div class="class-time-error"></div>
256          <div><input type="radio" name="classTime" id="Morning" value="Morning" required /><label for="Morning">Morning</label></div>
257          <div><input type="radio" name="classTime" id="Afternoon" value="Afternoon" required /><label for="Afternoon">Afternoon</label></div>
258          <div><input type="radio" name="classTime" id="Evening" value="Evening" required /><label for="Evening">Evening</label></div>
259        </fieldset>
260      </td>
261    </tr>
262
263    <tr>
264      <td>
265        <label for="SASID">SASID</label>
266        <input id="SASID" type="text" name="sasid" maxlength="250" />
267      </td>
268      <td>
269        <fieldset id="residence-area" class="no-border">
270          <legend>Residence Area</legend>
271          <div><input type="radio" name="residence" id="rural" value="Rural" /><label for="rural">Rural</label></div>
272          <div><input type="radio" name="residence" id="urban" value="Urban" /><label for="urban">Urban</label></div>
273        </fieldset>
274      </td>
275    </tr>
276
277    <tr>
278      <td>
279        <label for="country-of-birth">Country Born: <span style="color:#ff0000">*</span></label>
280        <input id="country-of-birth" type="text" required name="countryBorn"  />
281      </td>
282      <td>
283        <label for="birthdate">Birthdate <span style="color:#ff0000">*</span></label>
284        <input id="birthdate" type="date" required name="birthdate" placeholder="mm/dd/yyyy" autocomplete="bday" />
285      </td>
286    </tr>
287
288    <tr>
289      <td>
290        <fieldset id="gender" class="no-border">
291          <legend>Gender <span style="color:#ff0000">*</span></legend>
292          <div><input type="radio" name="gender" id="male" value="Male" required /><label for="male">Male</label></div>
293          <div><input type="radio" name="gender" id="female" value="Female" required /><label for="female">Female</label></div>
294          <div><input type="radio" name="gender" id="sex-other" value="Other" required /><label for="sex-other">Other</label></div>
295        </fieldset>
296      </td>
297      <td>
298        <fieldset id="pronouns" class="no-border">
299          <legend>Pronouns</legend>
300          <div><input type="radio" name="pronouns" id="he" value="He" /><label for="he">He</label></div>
301          <div><input type="radio" name="pronouns" id="she" value="She" /><label for="she">She</label></div>
302          <div><input type="radio" name="pronouns" id="they" value="They" /><label for="they">They</label></div>
303          <div><input type="radio" name="pronouns" id="pronouns-other" value="Other" /><label for="pronouns-other">Other</label></div>
304        </fieldset>
305      </td>
306    </tr>
307
308    <tr>
309      <td>
310        <fieldset id="ethnicity" class="no-border" data-required="true" data-container=".ethnicity-error">
311          <legend>Ethnicity <span style="color:#ff0000">*</span> (check one)</legend>
312          <div class="ethnicity-error"></div>
313          <div><input type="radio" required name="ethnicity" id="hispanic" value="Hispanic" /><label for="hispanic">Hispanic or Latino</label></div>
314          <div><input type="radio" required name="ethnicity" id="notHispanic" value="Not Hispanic" /><label for="notHispanic">Not Hispanic or Latino</label></div>
315        </fieldset>
316      </td>
317      <td>
318        <fieldset id="race" class="no-border" data-required="true" data-container=".race-error">
319          <legend>Race <span style="color:#ff0000">*</span> (must select at least one)</legend>
320          <div class="race-error"></div>
321          <div><input type="checkbox" class="formBox required" name="race" id="native" value="Native" /><label for="native">American Indian or Alaskan Native</label></div>
322          <div><input type="checkbox" class="formBox required" name="race" id="asian" value="Asian" /><label for="asian">Asian</label></div>
323          <div><input type="checkbox" class="formBox required" name="race" id="black" value="Black" /><label for="black">Black or African American</label></div>
324          <div><input type="checkbox" class="formBox required" name="race" id="pacificIslander" value="Pacific Islander" /><label for="pacificIslander">Native Hawaiian or Other Pacific Islander</label></div>
325          <div><input type="checkbox" class="formBox required" name="race" id="white" value="White" /><label for="white">White</label></div>
326        </fieldset>
327      </td>
328    </tr>
329
330    <tr class="education">
331      <td>
332        <fieldset id="education" class="no-border" data-required="true" data-container=".education-error">
333          <legend>Highest Education Level Completed on Entry: <span style="color:#ff0000">*</span></legend>
334          <div class="education-error"></div>
335
336          <div>
337            <input type="radio" name="education" id="noSchooling" value="No Schooling" required />
338            <label for="noSchooling">No Schooling</label>
339          </div>
340
341          <div>
342            <input type="radio" name="education" id="elementary" value="Elementary Grade" required aria-controls="elementaryGradeLabel elementaryGrade" />
343            <label for="elementary">Elementary Grade</label>
344
345            <div aria-live="polite">
346              <label id="elementaryGradeLabel" for="elementaryGrade" class="writeIn" style="display: block;">
347              Write in the grade level:<span style="color:#ff0000">*</span>
348            </label>
349              <input id="elementaryGrade" class="formBox writeIn" type="number" name="elementaryGrade" placeholder="Last grade completed" />
350            </div>
351          </div>
352
353          <div>
354            <input type="radio" name="education" id="highSchoolGrade" value="High School Grade" required aria-controls="highSchoolGradeLabel highSchoolGrade lastHighSchool"/>
355            <label for="highSchoolGrade">High School Grade</label>
356
357            <div aria-live="polite">
358              <label id="highSchoolGradeLabel" for="highSchoolGrade" class="writeIn" style="display: block;">
359              Write in the grade level:<span style="color:#ff0000">*</span>
360            </label>
361              <input id="highSchoolGrade" class="formBox writeIn" type="number" name="highSchoolGrade" placeholder="Last grade  completed" />
362            </div>
363          </div>
364
365          <div>
366            <input type="radio" name="education" id="secondarySchoolDiploma" value="Secondary School Diploma" required aria-controls="lastHighSchool"/>
367            <label for="secondarySchoolDiploma">Secondary School Diploma</label>
368          </div>
369
370          <div>
371            <input type="radio" name="education" id="somePostSecondary" value="Some Post-Secondary/Post-Secondary Degree" required aria-controls="lastHighSchool" />
372            <label for="somePostSecondary">Some Post-Secondary/Post-Secondary Degree</label>
373          </div>
374
375          <div id="lastHighSchool" aria-live="polite">
376            <label for="lastHighSchoolAttended">Last High School Attended <span style="color:#ff0000">*</span><label>
377              <br />
378            <input id="lastHighSchoolAttended" type="text" required name="lastHighSchoolAttended" maxlength="100" />
379          </div>
380
381        </fieldset>
382      </td>
383      <td>
384        <fieldset id="education-location" class="no-border" data-required="true" data-container=".education-location-error">
385          <legend>Highest Education Level Location <span style="color:#ff0000">*</span></legend>
386          <div class="education-location-error"></div>
387          <div><input type="radio" name="educationLocation" id="usBased" value="US Based" required /><label for="usBased">US-based Schooling</label></div>
388          <div><input type="radio" name="educationLocation" id="nonUsBased" value="Non-US Based" required /><label for="nonUsBased">Non-US-based Schooling</label></div>
389        </fieldset>
390      </td>
391    </tr>
392
393    <tr>
394      <td>
395        <fieldset id="employment-status" class="no-border" data-required="true" data-container=".employment-status-error">
396          <legend>Employment Status <span style="color:#ff0000">*</span></legend>
397          <div class="employment-status-error"></div>
398          <div><input type="radio" name="employment" value="Full Time" id="employedFull" required /><label for="employedFull">Employed, Full Time</label></div>
399          <div><input type="radio" name="employment" value="Part Time" id="employedPart" required /><label for="employedPart">
399Employed, Part Time</label></div>
400          <div><input type="radio" name="employment" value="Unemployed seeking employment" id="unemployed" required /><label for="unemployed">Unemployed, seeking employment</label></div>
401          <div><input type="radio" name="employment" value="Not looking for work" id="notLooking" required /><label for="notLooking">Not looking for work</label></div>
402          <div><input type="radio" name="employment" value="Unavailable for work" id="unavailable" required /><label for="unavailable">Unavailable for work</label></div>
403          <div><input type="radio" name="employment" value="Retired" id="retired" required /><label for="retired">Retired</label></div>
404          <div><input type="radio" name="employment" value="Unemployed with Separation Notice" id="unEmployedWithNotice" required /><label for="unEmployedWithNotice">Unemployed with Separation Notice</label></div>
405        </fieldset>
406      </td>
407      <td>
408        <fieldset id="miscellaneous-characteristics" class="no-border">
409          <legend>Miscellaneous Characteristics<br /> <span style="font-weight: 400">(Check all that apply)</span></legend>
410          <div><input type="checkbox" name="misc" value="Receive Public Assistance" id="receivePublicAssistance" /><label for="receivePublicAssistance">Receive Public Assistance</label></div>
411          <div><input type="checkbox" name="misc" value="Immigrant" id="immigrant" /><label for="immigrant">Immigrant</label></div>
412          <div><input type="checkbox" name="misc" value="Community/Alt. Corrections" id="communityAltCorrections" /><label for="communityAltCorrections">Community/Alt. Corrections</label></div>
413          <div><input type="checkbox" name="misc" value="Mother Under 17- C.G.S.10-73d" id="mother" /><label for="mother">Mother Under 17- C.G.S.10-73d</label></div>
414          <div><input type="checkbox" name="misc" value="Needs Child/Dependent Care" id="childCare" /><label for="childCare">Needs Child/Dependent Care</label></div>
415          <div><input type="checkbox" name="misc" value="Needs Transportation" id="needsTransportation" /><label for="needsTransportation">Needs Transportation</label></div>
416        </fieldset>
417      </td>
418    </tr>
419
420    <tr>
421      <td>
422        <fieldset id="referral" class="no-border" data-required="true" data-container=".referral-error">
423        <legend>How did you hear about Adult Education? <span style="color:#ff0000">*</span><br /> <span style="font-weight: 400">(Check all that apply)</span></legend>
424        <div class="referral-error"></div>
425        <div><input type="checkbox" name="hearAboutUs" class="required" value="Internet Search" id="internetSearch" /><label for="internetSearch">Internet Search</label></div>
426        <div><input type="checkbox" name="hearAboutUs" class="required" value="Brochure" id="brochure" /><label for="brochure">Brochure</label></div>
427        <div><input type="checkbox" name="hearAboutUs" class="required" value="Social Media" id="socialMedia" /><label for="socialMedia">Social Media</label></div>
428        <div><input type="checkbox" name="hearAboutUs" class="required" value="School Counselor" id="schoolCounselor" /><label for="schoolCounselor">School Counselor</label></div>
429        <div><input type="checkbox" name="hearAboutUs" class="required" value="Adult Ed Student" id="adultEdStudent" /><label for="adultEdStudent">Adult Ed Student</label></div>
430        <div><input type="checkbox" name="hearAboutUs" class="required" value="Friend/Family" id="friendFamily" /><label for="friendFamily">Friend/Family</label></div>
431        <div><input type="checkbox" name="hearAboutUs" class="required" value="Local Job Service" id="localJobService" /><label for="localJobService">Local Job Service</label></div>
432        <div><input type="checkbox" name="hearAboutUs" class="required" value="Community Agency" id="communityAgency" /><label for="communityAgency">Community Agency</label></div>
433        <div><input type="checkbox" name="hearAboutUs" class="required" value="Other" id="other" /><label for="other">Other</label></div>
434      </fieldset>
435      </td>
436      <td></td>
437    </tr>
438  </table>
439
440
441<hr>
442
443
444<table role="presentation" cellspacing="0" cellpadding="0" class="formTable">
445  <col width="50%">
446  <col width="50%">
447  <tr>
448    <td colspan="2">
449      <label for="home-address">Home Street Address <span style="color:#ff0000">*</span></label>
450      <input id="home-address" type="text" required name="homeStreet" autocomplete="address-line1" />
451    </td>
452  </tr>
453  <tr>
454    <td>
455      <label for="zip-code">
455Zip Code <span style="color:#ff0000">*</span></label>
456      <input id="zip-code" type="text" required name="homeZip" maxlength="10" autocomplete="postal-code" aria-describedby="zip-format" />
457      <span class="sr-only" id="zip-format">(max length 10 characters)</span>
458    </td>
459    <td>
460      <label for="city">City <span style="color:#ff0000">*</span></label>
461      <input id="city" type="text" required name="homeCity" autocomplete="address-level2" />
462    </td>
463  </tr>
464  <tr>
465    <td>
466      <label for="county">County </label>
467      <input id="county" type="text" name="homeCounty" />
468    </td>
469    <td>
470      <label for="state">State <span style="color:#ff0000">*</span></label>
471      <input id="state" type="text" required name="homeState" autocomplete="address-level1" />
472    </td>
473  </tr>
474  <tr>
475    <td colspan="2">
476      <label for="email-2">Email Address <span style="color:#ff0000">*</span></label>
477      <input id="email-2" type="text" required name="email" maxlength="250" data-display="email-2" autocomplete="email" aria-describedby="email-format" />
478      <span class="sr-only" id="email-format">Please enter a valid email address (max length 60 characters)</span>
479    </td>
480  </tr>
481</table>
482
483
484<hr>
485
486
487<table role="presentation" class="formTable">
488  <tr>
489    <td>
490      <strong>Phone Number</strong> <span style="color:#ff0000">*</span> (fill in at least one)
491      <div class="phone-number-error"></div>
492    </td>
493  </tr>
494  <tr>
495    <td>
496      <label for="homePhoneNumber">Home Phone</label>
497      <input type="tel" id="homePhoneNumber" name="homePhoneNumber" maxlength="250" data-container=".phone-number-error" autocomplete="tel" />
498    </td>
499  </tr>
500  <tr>
501    <td>
502      <label for="cellPhoneNumber">Mobile Phone</label>
503      <input type="tel" id="cellPhoneNumber" name="cellPhoneNumber" maxlength="250" />
504    </td>
505  </tr>
506  <tr>
507    <td>
508      <label for="workPhoneNumber">Work Phone</label>
509      <input type="tel" id="workPhoneNumber" name="workPhoneNumber" maxlength="250" />
510    </td>
511  </tr>
512</table>
513
514<hr>
515
516<fieldset class="no-border">
517  <legend><strong>Parent/Guardian of:</strong> <span style="font-weight: 400">(Check all that apply and list number)</span></legend>
518
519  <table role="presentation" class="formTable">
520    <tr>
521      <td>
522        <div>
523          <input type="checkbox" name="parentOf" id="fiveYears" value="Five Years and Younger" />
524          <label for="fiveYears">Child(ren) 5 years and younger</label>
525        </div>
526      </td>
527      <td>
528        <label for="children-five-and-younger" style="font-weight: 400">If yes, how many and what school?</label>
529        <input id="children-five-and-younger" type="number" name="chlidrenFiveYearsAndYounger" min="0" />
530      </td>
531    </tr>
532    <tr>
533      <td>
534        <div>
535          <input type="checkbox" name="parentOf" id="sixToTenYears" value="Six to Ten Years" />
536          <label for="sixToTenYears">Child(ren) 6 to 10 years</label>
537        </div>
538      </td>
539      <td>
540        <label for="children-six-to-ten" style="font-weight: 400">If yes, how many and what school?</label>
541        <input id="children-six-to-ten" type="number" name="chlidrenSixToTenYears" min="0" />
542      </td>
543    </tr>
544    <tr>
545      <td>
546        <div>
547          <input type="checkbox" name="parentOf" value="Eleven to Eighteen Years" id="elevenToEightteenYears" />
548          <label for="elevenToEightteenYears">Child(ren) 11 to 18 years</label>
549        </div>
550      </td>
551      <td>
552        <label for="children-eleven-to-eighteen" style="font-weight: 400">If yes, how many and what school?</label>
553        <input id="children-eleven-to-eighteen" type="number" name="chlidrenElevenToEighteenYears" min="0" />
554      </td>
555    </tr>
556  </table>
557</fieldset>
558
559
560
561  <hr />
562
563
564  <section>
565    <h3>Emergency Contact Information</h3>
566    <table role="presentation" cellspacing="0" cellpadding="0" class="formTable emergencyContact">
567      <tr>
568        <td>
569          <label for="emergency-contact">Name of Emergency Contact <span style="color:#ff0000">*</span></label>
570          <input id="emergency-contact" type="text" required name="emergencyContact" maxlength="250" />
571        </td>
572        <td>
573          <label for="emergency-phone">Emergency Telephone <span style="color:#ff0000">*</span></label>
574          <input id="emergency-phone" type="tel" required name="emergencyPhone" maxlength="250" />
575        </td>
576      </tr>
577    </table>
578  </section>
579
580
581  <hr />
582
583
584  <section>
585    <h3>Employer</h3>
586    <table role="presentation" cellspacing="0" cellpadding="0" class="formTable employer">
587      <tr>
588        <td>
589          <label for="employer">Name of Employer</label>
590          <input id="employer" type="text" name="employer" maxlength="250" />
591        </td>
592        <td>
593          <label for="employer-phone">Employer Phone</label>
594          <input id="employer-phone" type="tel" name="employerPhone" maxlength="250" />
595        </td>
596      </tr>
597      <tr>
598        <td colspan="2">
599          <label for="employer-address">Employer Address</label>
600          <input id="employer-address" type="text" name="employerAddress" maxlength="500" />
601        </td>
602      </tr>
603    </table>
604  </section>
605
606
607  <hr />
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858  
859
860  
861
862
863  <strong>I understand (must select all 4): <span style="color:#ff0000">*</span></strong>
864  <div class="waiver-error"></div>
865  <div class="half">
866    <fieldset id="confidential-field" data-error="You must check this checkbox" data-required="true" class="no-border" data-container=".confidential-error">
867      <div class="confidential-error"></div>
868      <input type="checkbox" class="formBox required" name="waiver" id="confidential" value="Confidential" required />
869      <label for="confidential">That student information is confidential and will only be used for program administration, research and evaluation purposes.</label>
870    </fieldset>
871  </div>
872
873  <div class="half">
874    <fieldset id="social-security-field" data-error="You must check this checkbox" data-required="true" class="no-border" data-container=".ss-error">
875      <div class="ss-error"></div>
876      <input type="checkbox" class="formBox required" name="waiver" id="social-security" value="Social Security" required />
877      <label for="social-security">I will provide my social security number if I have one.</label>
878    </fieldset>
879  </div>
880
881  <div class="half">
882    <fieldset id="tests-field" data-error="You must check this checkbox" data-required="true" class="no-border" data-container=".tests-error">
883      <div class="tests-error"></div>
884      <input type="checkbox" class="formBox required" name="waiver" id="tests" value="Tests" required />
885      <label for="tests">I will take all pre/post tests as required.</label>
886    </fieldset>
887  </div>
888
889  <div class="full">
890    <fieldset id="photo-id-field" data-error="You must check this checkbox" data-required="true" class="no-border" data-container=".photo-id-error">
891      <div class="photo-id-error"></div>
892      <input type="checkbox" class="formBox required" name="waiver" id="photo-id" value="Photo ID" required />
893      <label for="photo-id">I will provide a photo I.D. and address verification.</label>
894    </fieldset>
895  </div>
896
897  <br />
898
899  <fieldset id="photo-release" class="no-border" data-required="true" data-container=".photo-release-error">
900    <legend>Photo release (select one): <span style="color:#ff0000">*</span></legend>
901    <div class="photo-release-error"></div>
902    <div class="half">
903      <input type="radio" name="photoRelease" id="photoReleaseYes" value="Yes" />
904      <label for="photoReleaseYes">I agree to have my name or picture/video appear in any Wallingford Adult Education publications.</label>
905    </div>
906    <div class="half">
907      <input type="radio" name="photoRelease" id="photoReleaseNo" value="No" />
908      <label for="photoReleaseNo">I do not wish to have my name or picture/video appear in any Wallingford Adult Education publications.</label>
909    </div>
910  </fieldset>
911
912  <br />
913
914  <table role="presentation" cellspacing="0" cellpadding="0" class="formTable">
915    <tr>
916      <td>
917        <label for="applicant-signature">Applicant Signature <span style="color:#ff0000">*</span></label>
918        <input id="applicant-signature" type="text" required name="applicantSignature" maxlength="250" />
919      </td>
920      <td>
921        <label for="signature-date">Date <span style="color:#ff0000">*</span></label>
922        <input id="signature-date" type="date" required value="2026-10-04" name="todaysDate" maxlength="250" placeholder="mm/dd/yyyy" data-display="signature" />
923      </td>
924    </tr>
925  </table>
926
927  <br />
928
929  <p>
930    Data Matching is used to improve Adult Education performance and serve our students. By signing this form, I give permission to the Connecticut State
931    Department of Education to share my data with other agencies.
932  </p>
933
934  <label>Check this box <input type="checkbox" name="OptInToStateAgencyDataMatching" value="Yes" />to opt in to State Agency Data Matching.</label>
935
936
937  <hr />
938
939
940  <p>
941  <input type="text" name="Subject" value="" class="subjClass" /><input type="text" name="SubjectDate" value="EAAAAJ67e1n9rbWjYLrDIRXZ0X7sXTqmB3JWnwDjTYaOa5FAWP8LB6QiMF2JlvU5kIaaDg==" class="subjClass" /><input type="text" name="SubjectDomain" value="EAAAAB3nTmdhbwkdUxjZnQ8tUZkQ2CtnLd7GpoX6xTt4ibyemisjBTkRD8SBi6/bc6w37g==" class="subjClass" />
942  <input id="btnSubmit" type="submit" class="submit" value="Submit Form" />
943  </p>
944
945
946</form>
947
948
949<script>
950    $(function () {
951
952        let validator = new WS_Form_Validator({ 'selector': '#StudentInfoForm' });
953
954        resetSubmitBtn();
955
956        $('#StudentInfoForm').submit(function (e) {
957            e.preventDefault();
958
959            // Make sure one of the phone numbers has been filled in
960            let home_number = document.getElementById('homePhoneNumber');
961            let cell_number = document.getElementById('cellPhoneNumber');
962            let work_number = document.getElementById('workPhoneNumber');
963
964            if (home_number.value.trim().length == 0 && cell_number.value.trim().length == 0 && work_number.value.trim().length == 0) {
965                validator.append_error(home_number, 'You must fill in at least one number');
966                home_number.focus();
967                return;
968            }
969
970            $('#btnSubmit').val('Submitting...').prop('disabled', true);
971
972            var formData = $(this).serialize() + '&ValidateOnly=1'
973
974            $.post('/adult-education-enrollment-form/', formData, function (data) {
975                if (data && data.length > 0) {
976                    alert(data);
977                    resetSubmitBtn();
978                }
979                else {
980                    //remove submit handler and submit the form
981                    $('#StudentInfoForm').off('submit').submit();
982                }
983            });
984        });
985    });
986
987    function resetSubmitBtn() {
988        $('#btnSubmit').val('Submit Form').prop('disabled', false);
989    }
990</script>
990
991
992
993
994
995
996    <!-- cms end -->
997
998    </div><!--/content-->
999    <aside aria-label="Sidebar"><nav id="sidenav" aria-label="Sidebar"><ul><li class="on"><a href="/adult-education-enrollment-form/" target="_self">Adult Education Enrollment Form</a> </li><li ><a href="/academic-programs/adult-basic-education/" target="_self">Adult Basic Education (ABE)</a> </li><li ><a href="/academic-programs/english-as-a-second-language/" target="_self">English as a Second Language (ESL)</a> </li><li ><a href="/academic-programs/family-literacy/" target="_self">Family Literacy</a> </li><li ><a href="/academic-programs/citizenship/" target="_self">Citizenship</a> </li><li ><a href="/academic-programs/high-school-credit-diploma-program/" target="_self">High School Credit Diploma Program (CDP)</a> </li><li ><a href="/academic-programs/national-external-diploma-program/" target="_self">National External Diploma Program (NEDP)</a> </li><li ><a href="/academic-programs/ged-preparation/" target="_self">GED Preparation</a> </li><li ><a href="/academic-programs/eat-around-the-world/" target="_self">ESL - Eat Around the World</a> </li></ul></nav></aside>
1000
1001  </div>
1002</main>
1003
1004<footer>
1005	<div class="fatFooter">
1006
1007		<address class="column">
1008			<p><strong>Wallingford Adult Ed</strong></p>
1009
1010			<p>
1011				<span>
1012					4 Fairfield Blvd., Suite 1<br />
1013					Wallingford, CT 06492<br />
1014				</span>
1015				<a href="/driving-directions/?LocationID=1">Get Directions</a>
1016			</p>
1017
1018			<p>
1019				For questions or office hours&nbsp;call:<br />
1020				<a href="tel:2032943900">203-294-3900</a>
1021			</p>
1022		</address> <!-- .column -->
1023
1024		<div class="column">
1025			<form id="footer-email-signup" action="/email-signup/" method="post" class="reverse">
1026				<label for="email-signup">Email Signup</label>
1027				<input id="email-signup" type="text" name="Email" placeholder="Email Address" required data-display="email address"/>
1028				<button class="button blue" type="submit">Submit</button>
1029			</form>
1030
1031			<ul class="social">
1032				<li><a href="https://www.facebook.com/WallingfordAdultEducation/" rel="noopener noreferrer nofollow" aria-label="Wallingford Adult Ed on Facebook">
1033					<svg height="18.49px" width="9.68px" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 320 512" role="img" aria-label="Facebook icon"><path fill="currentColor" d="M279.14 288l14.22-92.66h-88.91v-60.13c0-25.35 12.42-50.06 52.24-50.06h40.42V6.26S260.43 0 225.36 0c-73.22 0-121.08 44.38-121.08 124.72v70.62H22.89V288h81.39v224h100.17V288z"></path></svg>
1034
1035				</a></li>
1036				<li><a href="https://www.youtube.com/@WallingfordAdultEd" rel="noopener noreferrer nofollow" aria-label="Wallingford Adult Ed on YouTube">
1037					<svg  height="16px" width="23px" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 576 512" role="img" aria-label="YouTube icon"><path fill="currentColor" d="M549.655 124.083c-6.281-23.65-24.787-42.276-48.284-48.597C458.781 64 288 64 288 64S117.22 64 74.629 75.486c-23.497 6.322-42.003 24.947-48.284 48.597-11.412 42.867-11.412 132.305-11.412 132.305s0 89.438 11.412 132.305c6.281 23.65 24.787 41.5 48.284 47.821C117.22 448 288 448 288 448s170.78 0 213.371-11.486c23.497-6.321 42.003-24.171 48.284-47.821 11.412-42.867 11.412-132.305 11.412-132.305s0-89.438-11.412-132.305zm-317.51 213.508V175.185l142.739 81.205-142.739 81.201z"></path></svg>
1038
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1040				<li><a href="https://www.instagram.com/wallingford_adult_ed/" rel="noopener noreferrer nofollow" aria-label="Wallingford Adult Ed on Instagram">
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