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Career and College Readiness Intake Paperwork
Today's Date (MM/DD/YYY)
Social Security Number (SSN)
Legal Last Name:
Legal First Name:
Middle Name
Suffix:
Preferred Name (If you would like to be called something other than you legal name in class):
Birthdate (mm/dd/yyyy)
Sex
Male
Female
Non-binary
No Answer
Address
City
County
State
Zip Code
Home Phone: xxx-xxx-xxxx (May be the same as Mobile Phone)
Mobile Phone: xxx-xxx-xxxx
Work Phone: xxx-xxx-xxxx
Email
Contact Preference:
Home Phone
Mobile Phone
Work Phone
Any Phone
Emergency Contact Name
Emergency Relation:
Emergency Contact Phone: xxx-xxx-xxxx
Ethnicity:
Hispanic/Latino
Not Hispanic/Latino
Race
American Indian / Alaska Native
Asian
Black / African American
Native Hawaiian / Other Pacific Islander
White
Highest Grade Completed (select one)
No Schooling
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade - no diploma
10th grade - no diploma
11th grade - no diploma
12th grade - no diploma
Achieved Secondary School Diploma
Achieved Secondary School Equivalency (GED)
Completed some Postsecondary Education
Achieved Postsecondary Degree
Highest Grade Location
U.S. Based Schooling
Non-U.S. Based Schooling
Employment Status at Program Entry (select one)
Employed - Full-Time
Employed - Part-Time
Unemployed
Not Looking for Work
Unavailable for Work
Retired
Employed with Separation Notice
Barriers to Employment: (select all that apply)
Cultural Barriers
Disabled
Displaced Homemaker
Low Income
English Language Learner
Ex-Offender
Exhausting TANF within 2-years
Foster Care Youth - Current or aged out system
Homeless
Long-term Unemployed 27+ consecutive weeks
Low Literacy Levels
Migrant farmworker
Seasonal farmworker
Single Parent or Guardian
None apply
Native Language (select one)
English
Chinese
German
Somali
Cambodian
French
Spanish
Korean
Other ________________
Additional Languages
Other Language spoken
Speak
Read
Write
Additional Languages
Other Language spoken
Speak
Read
Write
Additional Languages
Other Language spoken
Speak
Read
Write
Learned about this Program? (select one)
Friend or Family Member
Online/Internet (website, search, social media, etc)
Newspaper or Magazine
Pamphlet or brochure
Employer
Radio or Tv
Court or Court Order
Catalog
College Advisor
Other
Public Assistance Accessing (Select all that apply)
Unemployment
Food Stamps
WIC
Social Security
WIOA Enrollment (select all that apply)
Title I: Adult job placement services
Title I: Youth job placement services
Title I; Dislocated worker job placement services
Title IV: Vocational Rehabilitation
Title III: Wagner-Peyser services (unemployment insurance)
Referred by Agency?: (select one)
Career Pathways
Community based literacy organization
Department of Corrections
Department of Health & Welfare
Department of Labor
Employment Training
Even Start/Head Start
Faith-based Organization
Jail
Juvenile Detention
Local public school
One-Stop/Workforce Center
Vocational Rehabilitation
Other
None
I give permission for the information collected in the LiteracyPro System (LACES) to be used for the purposes of client referrals to WIOA partners, and in data sharing for program reporting purposes within the Division of Career & Technical Education, and GED Testing Services. I understand the Adult Education program will protect my confidentiality and at no time will this information be given to any other party without my express written consent.
Student Signature
Parent/Guardian Signature: (only if under 18)
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