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Adult Education and Literacy Student Intake Form for FY 2021

Thank you for your interest in attending Adult Education classes at Sauk Valley Community College.

We are no longer accepting new students as our school year will be ending in June. If you would like to join the interest list for classes that begin in August, please contact our office at 815-835-6310.

Adult Education and Literacy Student Intake Form FY2021

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

    1. Referral from WIOA Core Partner or One-Stop?
    2. Gender
    3. Are you Hispanic or Latino ?(Or, are you of Spanish origin?)
    4. Are you from one or more of the following racial groups? Select All That Apply - required if student is not Hispanic nor Latino
    5. English is a Second Language?

Contact Information

Education/Employment

    1. School Type
    2. U.S. High School Equivalency upon entry?
    3. U.S. Diploma upon entry?

Student Status

  1. Please select one
  1. How did you hear about the program?
  2. Do you receive Public Assistance?
  3. Barriers to Employment Information Please check all that apply.
  4. Please check all that apply.