Preview Registration – Mercer Community Education and Training

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STUDENT INFORMATION

PROGRAM YEAR 2022-23

Student ID

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Intake Date

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Updated:

Name:*

Please carefully type your legal name.

Are you currently a student at any high school in the state of New Jersey?*

Yes

PLEASE NOTE: You will not be able to submit this form if you are currently a student with any high school in the state of New Jersey. If you wish to exit your current program so that you may join our program, click here to download the exit interview form.

Social Security Number:

We do not require you to provide this number, but providing it helps us to track your accomplishments as well as match you with any resources you might need. As always, we keep all of your data private and secure.

Address:*

Please upload a favorite photo of yourself so that we can use it for your student ID.

Because we are using this for your student ID, please include only your head and shoulders in the image.

Max. file size: 2 MB.

Mobile Phone Number:*

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.

Home Phone Number:

You can leave this blank if you do not have a home phone number.

Email:*

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.

Date of Birth:*

Age:

Gender:*

Male

Female

Other

Any student age 16-21 years old must submit a completed and signed Certification form from the last school he/she attended before starting with us. If you do not already have a copy of this form, you can download and print it by clicking the link below.

Click here to download and print the required certification form.

Are you a US Citizen?*

We accept ALL students, regardless of whether you answer YES or NO.

Yes

Country of Birth*

Are you a veteran?*

Select the statement that best describes you.

I am not a veteran.

I am a veteran with less than 180 days of active duty.

I am a veteran with at least 180 days of active duty.

I am a veteran who served in a war or expedition with an authorized campaign badge.

Please list any other legal names you have had in the past.

For example, if you are married and your last name has changed, list your previous last name here. If you have never had a different name, leave it blank.

Ethnicity: Are you Hispanic?*

NOTE: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race, refers to Hispanic ethnicity.

Yes

Race:*

Select all that apply.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Name of Emergency Contact:*

Who can we contact if we cannot reach you?

Emergency Contact's Phone Number:*

Employment Information

Employment Status: (Select the statement that best describes you.)*

I am EMPLOYED Full Time.

I am EMPLOYED Part Time.

I am UNEMPLOYED.

I am UNEMPLOYED – Not looking for work.

I am UNEMPLOYED – Unavailable for work.

I am Retired.

I am Employed With Separation Notice.

Employer/Company Name:*

When were you hired?*

If you do not remember the exact date you were hired, you can choose the date that is your best estimate of when you were hired.

YYYY

Educational Information

Highest Education Level Completed on Entry*

Please select the highest grade level that you have completed.

Additional Education Level

Please select any of the following additional educational levels you have completed.

Career Certification/License/Certificate (no degree)

College or Professional degree (Associates Degree)

College or Professional degree (Bachelors Degree)

College Graduate or Professional degree (Beyond Bachelors Degree)

Highest Education Level Completed on Entry Loc*

Wher have you completed most of your education so far?

U.S. Based Schooling

Non U.S. Based Schooling

What is the name of the last school you attended?*

Household Information

Residential Institution Status:*

Please select the statement that best describes you.

I am a resident at a correctional facility.

I am a Community Corrections participant.

I am a resident at a medical/group/nursing home.

None of these apply to me.

Demographics

Do you have any physical, mental, or learning impairments?

Yes

Please select the statement that best describes where you live:*

I live in an urban area (inside the city or in a housing addition or acondo or an apartment).

I live in a rural area (outside the city or away from other housing or businesses).

Do you currently receive public assistance?*

Hint: Organizations such as Temporary Assistance For Needy Families (TANF), SNAP (food stamps), SSI and WIC are examples of public assistance.

Yes

Do you have a low level of income?*

Hint: Having a low level of income means that you do not have enough income to pay your bills.

Yes

Are you a displaced homemaker?*

Hint: A YES response means you were previously a stay at home mom or dad, but you are now seeking work due to a change in your household situation.

Yes

Are you a single parent?*

Yes

Are you a dislocated worker?*

Hint: A YES answer means that you were laid off from your job due to the company moving away.

Yes

Are you a dependent yourself, or do you claim to have dependent(s) in your household?*

Hint: A YES response means that either someone claims you as a dependent OR you claim to have dependent(s) yourself.

Yes

Household Size: How many people live in your household, including yourself?*

Please enter a number greater than or equal to 1.

Annual Family Income (Approximately how much is your family income for a year?)*

We accept ALL students, regardless of income level.

Are you currently, or have you ever been, in foster care?*

Yes

Are you currently homeless, or have you run away from your home?*

A YES response means that you DO NOT have a permanent, regular nighttime residence (other than a vehicle, a shelter, or temporarily staying with a friend).

Yes

Do you speak a language other than English at home?*

Yes

What is the language you first learned as a child?*

We have many resources to help our students overcome barriers that might make it difficult to come to school. Please select any of the statements listed below that apply to you, as we may be able to help!*

You may select more than one statement.

Migrant/Seasonal Farm Worker:*

Please select the option that best describes you:

No, I am NOT a migrant farmworker.

I am a migrant farmworker.

I am a migrant AND seasonal farmworker.

I am the dependent of a migrant farmworker.

Active Military:*

Please select the option that best describes you:

No, I am not active military.

Yes, I am active military.

I am the spouse of someone who is active military.

Are you involved in a Vocational Rehabilitation agency?*

If you don't recognize any of these choices, select NO or UNKNOWN.

Yes

Unknown

Do you utilize Wagner Peyser Employment services?*

Hint: Wagner-Peyser employment services are federally-funded Unemployment Services, which connects employers with job seekers.

Yes

Unknown

Have you ever been convicted of a crime?*

We accept ALL students, regardless of your answer.

Yes

Unknown

Cultural Barriers to Employment:*

Do you have any cultural barriers that might affect your job opportunities?

Yes

Unknown

Please select the option that best describes how you found us.*

I (We) hereby authorize the NJ Department of Education and the applicable HSE user jurisdiction (collectively the "HSE Testing Program") to provide copies of the documents, information, and/or records, including my name, enrollment information, education/career goals, CASAS test scores, HiSET or GED test account information and scores, and employment history, to Mercer Community Education and Training. This information will be kept strictly confidential and will be used only for program administration, research, and evaluation purposes. The specific information, documents, and/or records that I am authorizing the NJ Department of Education HSE Testing Program to release are to other state-funded adult education programs, employment offices and job training programs, public and private colleges, state executive offices, departments, and agencies, including the Department of Workforce Development (DWD), Division of Adult Education, and the Department of Education. In authorizing the release of this information, I hereby agree to the following:

I understand and acknowledge the HSE Testing Program's right to make an independent determination, at ts sole discretion of whether the information and records identified above are subject to disclosure under the HSE Testing Program's policies for disclosing information to third parties.
I hereby release the NJ Department of Education, the HSE Testing Program, its employees, its attorneys, its governing bodies, and its agents from any and all liability and claims of every kind and character that are based upon or relate in any way to the disclosure of information in accordance with this authorization of any actions of the third party identified above.
I agree that this authorization is valid until the NJ Department of Education; HSE Testing Program has received written notice from me (or from me and my parent or guardian, if I am a minor) withdrawing permission to disclose the information specified above to the third party identified above. If I withdraw permission, the NJ Department of Education; HSE Testing Program shall nevertheless remain fully protected from any and all claims and liability relating in any way to information released by the NJ Department of Education; HSE Testing Program before it receives my written withdrawal notice and to any actions of the third party.
I understand that, subject to its independent determination, the NJ Department of Education; HSE Testing Program will disclose the designated material that it has at the time it receives my request. I also understand that _unless I submit an additional request, the HSE Testing Program will not provide information that becomes available at a later date.

Please check the box below to acknowledge this authorization:*

I have read this authorization carefully and hereby acknowledge that I fully understand it. I further affirm that I am giving this authorization knowingly of my own free will.

If you have ever taken the HSE test under a different name, provide that name:

We 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.

Student Photo Release:*

I grant Mercer Community Education and Training, 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 Mercer Community Education and Training, its representatives and employees, to use and publish the same in print and/or electronically or online. I agree that Mercer Community Education and Training may use such photographs of me with or without my name for purposes including training and instruction manuals, promotional materials, and electronic documents.

I agree to the above described photo release statement.

I do not agree to the above described photo release statement.

Distance Learning Policy

The Community Education and Training Department of Mercer County Community College has a commitment to providing instruction and programs that meet the diverse learning needs of our students. The department has returned to in person instruction, but it provides this distance learning policy as a contingency plan, should remote operations need to resume at any given moment. Below is CET's contingency guiding policy for distance learning:

Instructors are responsible for the integrity of distance learning content.
Distance learning requires learners to access class and online learning portal through a personally owned, internet connected, reliable device.
Training for our students in web-based utilities is provided as part of class orientation, and instrnctors remain available to assist students as needed.
Students are expected to show an 'honest effort' at all work in a distance-learning environment.
Students will use various portals as part of their distance learning, and attendance will be recorded according to the time recorded in the portals.
Attendance and participation expectations are the same as for in person classes.
Students are expected to attend, participate, and persist in a distance learning opportunity. Students are expected to have device cameras on at all times, be attentive and participatory for class, and will have microphones muted except when being asked to contribute or ask a question.
Students are expected to present themselves online as if attending in person class (time, dress, language, and attitude).
Instructors will provide distance learning digital platform access information to students at the beginning of each session.
Students commit to attending in person classes or may attend virtually with the express written consent of the Director. Such requests will be addressed on a case-by-case basis.

Distance Learning Policy Agreement:*

I have read the policy above and will follow the protocols outlined above.

Student Signature*

Please type your full legal name, as this will serve as your electronic signature. This signature acknowledges that the information provided in this form is true and correct. Applicants who are under 18 years of age will require a parent/guardian signature as well.

Date*

Parent/Guardian Signature*

Parent/Guardian: Please type your full name, as this will serve as your electronic signature. This signature acknowledges that the information provided in this form is true and correct.

Date*

STUDENT INFORMATION

Employment Information

Educational Information

Household Information

Demographics

Distance Learning Policy

Instructors are responsible for the integrity of distance learning content.

Distance learning requires learners to access class and online learning portal through a personally owned, internet connected, reliable device.

Training for our students in web-based utilities is provided as part of class orientation, and instrnctors remain available to assist students as needed.

Students are expected to show an 'honest effort' at all work in a distance-learning environment.

Students will use various portals as part of their distance learning, and attendance will be recorded according to the time recorded in the portals.

Attendance and participation expectations are the same as for in person classes.

Students are expected to attend, participate, and persist in a distance learning opportunity. Students are expected to have device cameras on at all times, be attentive and participatory for class, and will have microphones muted except when being asked to contribute or ask a question.

Students are expected to present themselves online as if attending in person class (time, dress, language, and attitude).

Instructors will provide distance learning digital platform access information to students at the beginning of each session.

Students commit to attending in person classes or may attend virtually with the express written consent of the Director. Such requests will be addressed on a case-by-case basis.