Adult Education Student Intake Form FY24

General Contact Information
Name Name First Middle Last
Preferred/Chosen Name
Date of Birth Date of Birth / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Primary Phone Primary Phone - ### - ### ####
Email
Emergency Contact Name Emergency Contact Name First Last
Emergency Contact Phone Emergency Contact Phone - ### - ### ####
Sex

Sex Male Female
Marital Status

Marital Status Single Married Divorced Widowed Other Other
Are there any barriers to entry we can assist with?

Are there any barriers to entry we can assist with? Yes, documented disability as defined by ADA Not disabled Choose not to respond
Racial and Ethnic Survey

We are required by the State of Illinois to collect this information for statistical purposes. These items are required for registration to be complete.
Are you Hispanic or Latino (or are you of Spanish origin)?

Are you Hispanic or Latino (or are you of Spanish origin)? Yes No
Are you from one or more of the following racial groups? (Select all that apply)

Are you from one or more of the following racial groups? (Select all that apply) American Indian or Alaska Native Hispanic or Latino Black/African American Native Hawaiian or Other Pacific Islander White
Please identify your primary racial / ethnic group.

Please identify your primary racial / ethnic group. American Indian or Alaska Native Hispanic or Latino Black/African American Native Hawaiian or Other Pacific Islander White
Educational Background
Was English the second language you learned?

Was English the second language you learned? Yes No
If English is your second language, please provide your native language:
School type ("US based schooling" means you attended school in the United States)

School type ("US based schooling" means you attended school in the United States) US Based Schooling Non-US Based Schooling
What was the last grade you completed?
Do you already have a GED, High School Equivalency, or U.S. High School Diploma?

Do you already have a GED, High School Equivalency, or U.S. High School Diploma? Yes No
Employment Status
What is your current employment status?

What is your current employment status? Not in the Labor Force (will not enter work force) Employed Unemployed Employed but received notice of termination or military separation
If employed, please list the hours worked per week.
If employed, please list your occupation.
Do you receive Public Assistance?

Do you receive Public Assistance? Yes No
Barriers to Employment Information (please check all that apply)

Barriers to Employment Information (please check all that apply) Displaced Homemaker Homeless Person or Runaway Youth in Foster Care/Aged Out of System Migrant and Seasonal Farm worker English Language Learner, Low Literacy Levels, Cultural Barriers Low Income Individual with a Disability Single Parent Long-term Unemployed Exhausting TANF within 2 years Ex-Offender Not Applicable
Class Information
Select a program

Select a program GED Preparation (High School Equivalency) English as a Second Language (ESL)
Preferred Class Time

Preferred Class Time Morning Evening Either morning or evening is ok Online Morning, evening, or online is ok
How did you hear about the program?

How did you hear about the program? Friend or family member Employer Visiting the unemployment office and was referred Other Other
By signing this form with your digital signature, you acknowledge that Adult Education and Literacy can collect your data for enrollment.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

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Adult Education Student Intake Form FY24

Adult Education Student Intake Form FY24

General Contact Information

Racial and Ethnic Survey

Educational Background

Employment Status

Class Information