Adult Education and Literacy Student Intake Form

Information provided will be kept confidential in accordance with the Family Educational Rights and Privacy Act of 1974 (P.L. 93-380)

1. 1. Referral from WIOA Core Partner or One-Stop?

      1. Yes
      2. No
   2. If Yes , Name of Referring WIOA Partner/One Stop
   3. Social Security #
   4. Last Name
   5. First Name
   6. MI
   7. Date of Birth
   8. Gender

      1. Male
      2. Female
   9. Marital Status SingleMarriedDivorcedWidowedUnknown
   10. Are you Hispanic or Latino ?(Or, are you of Spanish origin?)

       1. Yes
       2. No
   11. Are you from one or more of the following racial groups? Select All That Apply - required if student is not Hispanic nor Latino

       1. American Indian or Alaska Native
       2. Asian
       3. Black/African American
       4. Native Hawaiian or Other Pacific Islander
       5. White
   12. Please identify your primary racial/ethnic group(Select One) American Indian or Alaska NativeAsianBlack/African AmericanNative Hawaiian or Other Pacific IslanderWhite
   13. English is a Second Language?

       1. Yes
       2. No
   14. If yes, please record Native Language

Contact Information

1. 1. Address
   2. City
   3. Zip
   4. Home Phone
   5. Work Phone
   6. County of Residence

Education/Employment

1. 1. School Type

      1. US Based Schooling
      2. Non-US Based Schooling
   2. Month/Year Last Enrolled
   3. Number of School Years Completed Please select on of the followingNo SchoolingGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12HS Diploma of Alternative CredentialGED or other High School EquivalencySome College, No DegreeCollege or Professional DegreeUnknown
   4. U.S. High School Equivalency upon entry?

      1. Yes
      2. No
   5. U.S. Diploma upon entry?

      1. Yes
      2. No
   6. If employed, what is your occupation?

Student Status

1. Please select one

   1. Not Disabled
   2. Documented Disability as Defined by ADA
   3. Chooses not to disclose
2. Students should select one of the 16 Career Clusters identified below as the career pathway they intend to follow: Agriculture Food & Natural Resources (Agribusiness Systems, Animal Systems, Environmental Service Systems, Food Products & Processing Systems, Natural Resources Systems, Plant Systems, Power, Structural & Technical Systems Architecture & Construction)Architecture & Construction (Construction, Design/Pre-Construction, Maintenance/Operations)Arts, A/V Technology & Communications (A/V Technology & Film, Journalism & Broadcasting, Performing Arts, Printing Technology, Telecommunications, Visual Arts)Business Management & Administration (Administrative Support, Business Information Management, General Management, Human Resources Management, Operations Management)Education & Training (Administration & Administrative Support, Professional Support Services, Teaching/Training)Finance (Accounting, Banking Services, Business Finance, Insurance, Securities & Investments)Government & Public Administration (Foreign Service, Governance, National Security, Planning, Public Management & Administration, Regulation, Revenue & Taxation)Health Sciences (Biotechnology Research & Development, Diagnostic Services, Health Informatics, Support Services, Therapeutic Services)Hospitality & Tourism (Lodging, Recreation, Amusements & Attractions, Restaurants & Food/Beverage Services, Travel & Tourism)Human Services (Consumer Services, Counseling & Mental Health Services, Early Childhood Development & Services, Family & Community Services, Personal Care Services)Information Technology (Information Support & Services, Network Systems, Programming & Software Development, Web & Digital Communications)Law, Public Safety, Corrections & Security (Correction Services, Emergency & Fire Management Services, Law Enforcement Services, Legal Services, Security & Protective Services)Manufacturing (Health, Safety & Environmental Assurance, Logistics & Inventory Control, Maintenance, Installation & Repair, Manufacturing Production Process Dev., Production, Quality Assurance)Marketing (Marketing Communications, Marketing Management, Marketing Research, Merchandising, Professional Sales)Science, Technology, Engineering & Mathematics (Engineering & Technology, Science & Mathematics)Transportation, Distribution & Logistics (Facility & Mobile Equipment Maintenance, Health, Safety & Environmental, Management, Logistics Planning & Management Services, Sales & Service, Transportation Operations, Transportation Systems/Infrastructure, Planning, Management & Regulation, Warehousing & Distribution Center, Operations)

1. 1. Do you live in? Rural AreaUrban Area with High UnemploymentNeither
   2. How did you hear about the program?

      1. One-Stop
      2. Employer
      3. Other
   3. Please select one of the following. Not in the Labor ForceEmployed but received notice of Termination or Military SeparationUnemployedEmployed Full-Time
   4. If employed, hours per week:
   5. Do you receive Public Assistance?

      1. Yes
      2. No
   6. If yes, Public Assist Number
   7. Barriers to Employment Information Please check all that apply.

      1. Displaced Homemaker
      2. Low Income
      3. Individual with a Disability
      4. Ex-Offender
      5. Homeless Person or Runaway
      6. Youth
      7. Single Parent
      8. Youth in Foster Care/Aged out of System
      9. Long-Term Unemployed
      10. Migrant and Seasonal Farmworker
      11. Exhausting TANF within 2 years
      12. English Language Learn
   8. Please check all that apply.

      1. In a Correctional Facility
      2. In a COMMUNITY CORRECTIONAL PROGRAM
      3. In OTHER INSTITUTIONAL SETTING

1. 1. I give permission to release my GED test scores from GED Testing Service LLC to the Adult Education Program Office at Sauk Valley Community College.

PLEASE TYPE YOUR FULL NAME AND TODAY'S DATE TO SERVE AS AN ELECTRONIC SIGNATURE.

1. 1. Electronic Student Signature
   2. Date