Free Eligibility Form - Tennessee

Eligibility for Enrollment in Adult Education
Tennessee Department of Labor and Workforce Development Division of Adult Education

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Adult Education is provided for individuals (A) who are at least 16 years of age; (B) who are not enrolled or required to be enrolled in secondary school under State law; and (C) who(i) lack sufficient mastery of basic educational skills to enable the individuals to function effectively in society;(ii) do not have a secondary school diploma or its recognized equivalent, and have not achieved an equivalent level of education; or (iii) are unable to read, write, or speak the English language. (Title II Workforce Investment Act, Section II, 203)

To be eligible for Adult Education services, applicants under the age of 18 must provide proof of official withdrawal from school as noted in TN Code 49-6-3001. (Board minutes, attendance screen shot, formal intent to register for home school or other official documentation approved by the Division of Adult Education.)

Student's Name
Last First Middle Maiden

SSN Student's Signature

Date of Birth Date

Student named above has been officially withdrawn from Public/Private School 00 - dropout under 18 Home School 10 - home school

School System and is coded as:

Signature Director of Schools Date Phone TO BE COMPLETED BY NOTARY State of appeared before me, Sworn to before me this , and the county of

Signature Parent / Guardian Date Phone

, , a Notary Public for the State of Tennessee. , 20
My commission Expires

Director of Schools/ Parent

personally

Name of Notary

day of

Notary Signature

Adult Education is a voluntary program whose primary function is to serve adults. No information concerning enrollment or attendance will be shared unless approved in advance by the individual and the Division of Adult Education.

LB-0872 (rev.6-07)