Adult Education Student Intake Form FY25
Adult Education Student Intake Form FY25
1
General Information
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2
Education & Employment
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3
Goals & Steps to Success
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4
Career Path
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5
GED Test Result Consent
General Information
Name
Name
*
First
Middle
Last
Last 4 of Social Security Number
Full SSN (for office use only)
Date of birth
Date of birth
*
/
MM
/
DD
YYYY
Are you 17 or younger?
*
Are you 17 or younger?
Yes
No
Please note
: Students 17 or younger MUST provide a drop letter from high school or Regional Office of Education.
Drop letter received:
Gender
*
Gender
Male
Female
Non-binary
Choose not to disclose
Marital status
Marital status
Single
Married
Divorced
Widow
Unknown
Address (must be an Illinois resident)
Address (must be an Illinois resident)
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
-------
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Gibraltar
Greece
Grenada
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Norway
North Korea
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
County
*
County
Adams
Brown
Cass
Calhoun
Hancock
Morgan
Pike
Schuyler
Scott
Other
Other
Country of Origin
Phone
Phone
*
-
###
-
###
####
Phone type
*
Phone type
Home
Mobile
Work
Email
*
Were you referred by another agency to JWCC?
*
Were you referred by another agency to JWCC?
Yes
No
If so, please list that agency.
*
Is English a secondary language for you?
*
Is English a secondary language for you?
Yes
No
If yes, please list your native language.
*
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 ethnic groups? Select all that apply.
*
Are you from one or more of the following ethnic groups? Select all that apply.
American Indian or Alaska Native
Asian
Black
Native Hawaiian or Pacific Islander
White
Emergency Contact Information
Name
Name
*
First
Last
Emergency contact's phone
Emergency contact's phone
*
-
###
-
###
####
Relationship to you
*
Please list any important medical issues you may have, and if so, appropriate actions for staff to take. If you have none, please type "N/A".
*
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Enter Your Email Address
*
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