Anderson Adult Education Center

Serving Districts 3, 4, & 5 864-260-5075

Application for 17 Year Old to Attend Anderson Adult Education

School Year ______

Student’s Name: ______

LastFirstMiddle Nick Name

Student ID Number: ______Present Grade: ______

Gender: M F Ethnic Code: ______Birthdate: ______Age: ______

Last School Attended: ______

______

AddressCityStateZipPhone

Parent(s)/Custodial Guardian(s):______

Address: ______

AddressCityStateZipPhone

Mother’s Work Phone: ______Extension: ______

Father’s Work Phone: ______Extension: ______

Reason for Request: ______

______

If Student is accepted into the 17 year old program:

We understand that the student must provide the necessary transportation.
We understand that the student will be ineligible for participation in athletics.
We understand that diploma units earned in the Adult Education Program will not transfer back to a regular high school.
We understand that the student will abide by attendance regulations set by the Program Director, the Anderson District Five, and the State Department of Education. Failure to abide by attendance regulations will result in dismissal from the program.

Student Signature: ______Date: ______

Parent/Custodial Guardian Signature: ______Date: ______

Note: (Adult Education) “Membership shall be limited to individuals who are 18 years of age or over and have left the elementary or secondary school, except when the local school board assigns students less than 18 years of age who are not officially in membership in a regular school. These students may be assigned to one or more classes of an adult education program when (1) they exhibit an unusual educational need or (2) they exhibit physical, social, or economic problems which can be served more effectively by the adult program.” SDE ASSURANCES: “No one under the age of 16 is assigned to the Adult Education Program for any reason”

BACK OF FORM MUST BE COMPLETED BY GUIDANCE COUNSELOR OR PRINCIPAL OF LAST SCHOOL ATTENDED.

Anderson Adult Education Center

Serving Districts 3, 4, & 5 864-260-5075

Referral for 17 Year Olds

School Year ______

Must be completed by school Guidance Counselor or Principal

Student’s Name______

LastFirstMiddle Nick Name

Check all criteria that apply:

______Missed too many days/failing for year.

______Too old for grade placement.

______Has already dropped out of school.

______17 year old not living at home, supporting self.

______Discipline Issues.

______Other (please explain): ______

______

Does Student have:An IEP? ______Yes _____NoA current 504 Plan? _____ Yes _____No

Is student on an attendance court order? _____Yes _____No

Is student on a Court Order of Probation? _____Yes _____No

Has student passes the HSAP?ELA _____Yes _____ No Math _____Yes _____No

Guidance Counselor’s Signature: ______Date: ______

Principal’s Signature: ______Date: ______

Program Director’s Signature: ______Date: ______

Superintendent’s Signature: ______Date: ______

Please attach the following documents:

______Copy of the Official Transcript and HSAP test scores

______Copy of Disciplinary printout

______Copy of Psychological file (if applicable)

______Copy of any Court Orders on file

Please list any outstanding fees or materials: ______

______

Please call the following number for additional information regarding this program: Anderson Adult Education Center 864-260-5075.