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NEW Covid-19 Information

Adult Education and Literacy Student Intake Form

Thank you for your interest in attending Adult Education classes at Sauk Valley Community College.  Please complete the Intake Form to register for classes.
Adult Education and Literacy Student Intake Form FY2022

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.

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