ADULT EDUCATION & LITERACY REFERRAL TO ARKANSAS ...

ADULT EDUCATION & LITERACY REFERRAL TO ARKANSAS REHABILITATION SERVICES (ARS)

The ____________________________ program in ______________________ would

(name of adult education or literacy program)

(town/state)

like to refer this student for ARS services. This student is working to obtain a GED?

diploma, and will most likely need accommodations to pass the GED? test. We

understand that if the student is accepted as an ARS client, ARS/RIDAC will administer the learning disabilities assessments required by GED Testing Service? to request and receive accommodations on the GED? test.

Student Name:

________________________________________________________ (first, middle, last)

Student Address:

Student Telephone: Student E-mail: Social Security #:

__________________________________________________________ __________________ Date of Birth:

In the event that this student is not eligible for ARS services, please complete the information below and return this form to ____________________________ program in

(name of adult education or literacy program)

___________________________________.

(town/state)

Reason(s) for ineligibility:__________________________________________________

______________________________________________________________________

______________________________________________________________________

For the reason(s) above, the Arkansas Department of Career Education, Adult Education Division, will assume responsibility for the cost of a learning disabilities evaluation for this student.

___________________________________

(ARS staff signature)

__________________________

(Date)

Page 1 of 4

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION FROM ADULT EDUCATION / LITERACY TO ARS

I give my permission to release information contained in the document(s) indicated below.

Please date, initial and check [] the appropriate items below.

[ ] Learning Disabilities Screening Results

[ ] Test of Adult Basic Education (TABE) scores

[ ] School records from: _____________________________________________________________

[ ] Other records from:

___________________

[ ] Other:___________________________________________________________________________

This release is valid for one year from the date of my signature, or until it is revoked in writing by me. I understand the information will be kept confidential and will not be shared with another agency without consent. This release form has been read out loud to me and I understand its contents.

Signature: ______________________________________________Date:

_____

Program Advocate's Signature:

Position_____________________

AUTHORIZATION FOR RELEASE OF INFORMATION FROM ARS TO THE ARKANSAS GED ADMINISTRATORTM

I , _________________________________, a student in the _____________________________ program in ______________________, Arkansas, authorize Arkansas Rehabilitation Services to release to the Arkansas GED AdministratorTM the indicated information (check and initial all items that apply) for accommodations request purposes:

_______ All psychological and achievement test results _______ All evaluations or diagnostic reports related to cognitive

processing/learning _______ All medical records or other information regarding my treatment including

psychological or psychiatric condition _______ Other:

Page 2 of 4

Please send this information to:

Attention: Arkansas GED AdministratorTM

Agency: Arkansas Department of Career Education, Adult Education Division, GED? Testing

Address: 801 Louisiana Street

Little Rock, AR 72201

Phone: 501.682.1976

Fax:

501.682.1982

E-mail: GED@

This release is valid for one year from the date of my signature, or until it is revoked in writing by me. I understand the information will be kept confidential and will not be shared with another agency without consent. This release form has been read out loud to me and I understand its contents.

Signature: ______________________________________________Date: _______________________

Program Advocate's Signature:

Position__________________

AUTHORIZATION FOR RELEASE OF INFORMATION FROM THE ARKANSAS GED ADMINISTRATORTM TO ADULT EDUCATON / LITERACY

I , _________________________________, a student in the _____________________________ program in ______________________, Arkansas, authorize the Arkansas GED AdministratorTM to release to ____________________________ the indicated information (check and initial all items

(name of adult education/literacy program)

that apply) for accommodations request purposes: _______ All psychological and achievement test results _______ All evaluations or diagnostic reports related to cognitive processing/learning _______ All educational records regarding my request for accommodations on the GED? tests. _______ Other:

Page 3 of 4

Please send this information to: Attention: _____________________________________ Program : __________________________________________________________ Address:

Phone: Fax: E-mail:

_____________________________ _____________________________ _____________________________

This release is valid for one year from the date of my signature, or until it is revoked in writing by me. I understand the information will be kept confidential and will not be shared with another agency without consent. This release form has been read out loud to me and I understand its contents.

Signature: ______________________________________________Date:

_____

Program Advocate's Signature:

Position__________________

Page 4 of 4

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