2024 Adult Education and Literacy Student Intake Form

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Thank you for your interest in attending Adult Education classes. Please complete the following registration form to enroll in class.
Information provided will be kept confidential in accordance with the Family Educational Rights and Privacy Act of 1974 (P.L.93-380).

How did you hear about the Adult Education program? *

BEST, Inc or One-Stop Center

Unemployment Office (IDES)

Illinois Department of Rehabilitation Services

Your employer

Family member

Friend

Other:

Required

Please type your Social Security Number.
*This information is required. This information will be kept secure. If you do not have a social security number, type 111-11-1111. *

Last Name *

First Name *

Middle Initial

Date of Birth *

YYYY

Gender *

Male

Female

What is your address? *

What city do you live in? *

What is your ZIP code? *

Phone Number *

County of Residence

Lee (Dixon, Amboy, Franklin Grove)

Ogle (Oregon, Mt. Morris, Polo, Byron)

Whiteside (Sterling, Rock Falls, Morrison, Prophetstown)

Other:

Clear selection

Which type of area do you live?

Rural area (small town)

Urban area with high unemployment (big city)

Neither

Clear selection

Marital Status

Single

Married

Divorced

Widowed

Unknown

Clear selection

Are you Hispanic or Latino? Or, are you of Spanish origin? *

Yes

Are you from one or more of the following racial groups? *Select all that apply. *

American Indian or Alaska Native

Asian

Black/African American

Native Hawaiian or other Pacific Islander

White

Other:

Required

Is English your second language? *

Yes

If you answered YES that English is your second language, what is your first language?

Where did you attend school? *

Attended school in the United States

Attended school in another country

What was the month and year when you left school?

What was the last grade you completed in school? *

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

Completed high school and earned diploma or high school equivalency (GED)

Completed some college, no degree earned

Earned college or professional degree

Not sure

Have your earned a GED or high school equivalency certificate in the United States? *

Yes

Have you earned a high school diploma in the United States? *

Yes

Please select your status:

I am NOT disabled.

I have a documented disability as defined by the Americans with Disabilities Act.

I choose not to share if I have a disability.

Clear selection

Which career cluster would you like to study or work in? Choose as many as you would like. *

Agriculture, Food, and Natural Resources - Do you enjoy working with animals? Are you interested in protecting the environment? Jobs include working on a farm, ranch, dairy, orchard, greenhouse, or plant nursery. You could also work in a clinic or laboratory as a scientist or engineer.

Architecture and Construction - Would you like to get paid to build the things people use everyday? Jobs include building highways, bridges, houses, and buildings. You might create the designs or plans for new structures. Or, you might use the plans to build it or manage the workers on the project.

Arts, Audio/Video Technology, and Communications - Do you like to perform in front of an audience? Are you a visual person or like to work with productions and technology? You might work for an audience as a performer or artist. This includes painters, dancers, sculptors, actors, and singers. Or, you might work behind the scenes to make a performance successful. This includes set designers, editors, broadcast technicians, and camera operators.

Business, Management, and Administration - Do you enjoy working with other people? Do you like to plan and organize activities? Business, management, and administrative workers give the support needed to make a business run. You might check employee time records or train new employees. Or, you might work as a top executive and provide the overall direction for a company or department.

Education and Training - Would you like to get paid to help others learn new things? Education and training workers guide and train people. As a teacher, you could influence young lives. You could also support the work of a classroom teacher as a counselor, librarian, or principal. You could coach sports activities or lead community classes.

Finance - Are you good at math? Do you like to work with numbers? Finance workers keep track of money. You might work in financial planning, banking, or insurance.

Government and Public Administration - Are you interested in politics? Are rules and laws important to you? Government and public administration workers help pass and enforce the law. You could work in national, state, or local government.

Health Science - Would you like to get paid for taking care of others? Health science workers promote health and wellness. They diagnose and treat injuries and disease. As a physician, dentist, or nurse, you could work directly with patients.

Hospitality and Tourism - Would you like to get paid to help people have fun? Hospitality and tourism workers help people enjoy vacations and entertainment activities. You might work at a restaurant, resort, sports arena, theme park, museum, or hotel.

Human Services - Do you care about people and want to help in some way? Human services workers help individuals and families meet their personal needs. You might work in a government office, hospital, nonprofit agency, nursing home, spa, hotel, or school. Or, you might work in your own home.

Information Technology - Would you like to get paid to work on computers? Information technology workers are in a growing and always changing field. You might work with computer hardware, software, multimedia, or network systems. You might design new computer equipment or work on a new computer game.

Law, Public Safety, Corrections, and Security - Do you like the idea of protecting people? Can you work in the face of danger? Do you want to help people figure out the legal system? Law, public safety, corrections, and security workers are found in a variety of settings. For example, you might guard the public and enforce the law as a police officer or security guard. Or, you might provide fire protection as a firefighter. Other workers provide legal services to people who commit crimes.

Manufacturing - Are you good working with your hands? Can you figure out how a machine works? Manufacturing workers work with products and equipment. You might design a new product, decide how the product will be made, or make the product. You might work on cars, computers, appliances, airplanes, or electronic devices.

Marketing - This career will prepare you to work on projects such as promotional campaigns, event planning and new sales techniques.

Science, Technology, Engineering, and Mathematics - Are you detail-oriented? Do you want to know how things work, or enjoy solving problems? Science, technology, engineering, and mathematics workers do scientific research in laboratories or the field. Others plan or design products and systems. Or, you might support scientists, mathematicians, or engineers as they do their work.

Transportation, Distribution, and Logistics - Have you always been fascinated by vehicles? Do you like to drive them or fix them? Transportation, distribution, and logistics workers move people and products by road, air, rail, and water. You might work as a driver, pilot, engineer, or captain.

Required

Are you currently working? *

No, I am not currently working

I am not working but I am looking for a job

I am working but I received notice of termination or military seperation

I am working full-time (30 to 40 hours per week)

I am working part-time (1 - 29 hours per week)

Required

How many hours a week do you work?

If you are not working, what is stopping you from working? *

I am a displaced homemaker *A displaced homemaker is someone who provided unpaid services to their family, such as a stay-at-home mom or dad, and currently is unemployed or underemployed but plans to find a job and begin a career.

Low income

I have a disability

Ex-offender

Homeless person or run-away

Youth

Single parent

I am in foster care or I aged out of foster care system

Long-term unemployed

Migrant or seasonal farmworker

Exhausting TANF within 2 years (TANF = Temporary Assistance for Needy Families)

I am an English language learner

I am working, I am NOT unemployed.

Required

Do you receive public assistance?

Yes

Clear selection

If you ARE living in an institutional setting, please select the setting where you live.
If you are NOT living in an institutional setting, you can skip this question.

Correctional facility

Community correctional program

Other institutional setting

Clear selection

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.
*

Yes

Required

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

Please Select Which Program *

GED

ESL

Clear form

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