Please fill out the form: (* denotes required fields)
First Name *
 Last Name *
Middle Name
 Suffix
Program * (must select at least one)
SASID
 Residence Area
Country Born *
 Birthdate *
Gender
 Native Language *
Race * (must select at least one)
 Ethnicity * (must select at least one)
Highest Education Level Completed on Entry: *
Write in the grade level:
Write in the grade level:
Last High School Attended *

 Highest Education Level Location *
Employment Status *
 Miscellaneous Characteristics (Check all that apply)
Home Street Address *
City *
 Zip Code *
County *
 State *
Phone Number *
Enter Phone Number *
 Email Address *
Parent/Guardian of: (Check all that apply and list number)
If yes, how many?
If yes, how many?
If yes, how many?

Emergency Contact

Name of Emergency Contact *
 Emergency Phone *
Relationship to Emergency Contact *

Employment Information

Name of Employer
 Employer Address
Employer Phone
Student Goals * (Select all that apply and must select at least one goal)
Economic Goals
 Societal/Community Goals
Educational Goals
 Family Goals
All students must check one category below: *
Low-level Literacy
ABE, GED, NEDP, CDP students
(All students who do not have an SSD at entry)
 English Language Learner/Cultural Barriers
ESL/ELL students

Check all that apply:

Cultural Barriers
Do you feel your culture, beliefs, or practices makes finding/keeping a job harder?
Disabled
Do you wish to disclose any disability that limits your life activities?
Displaced Homemaker
Are you a former homemaker who is having trouble finding a job or a better job?
Low Income/Public Assistance
Do you have a low income? Do you receive SNAP, TANF, SSI, or local public assistance? Are you a foster child or homeless?
Ex Offender
Do you have a criminal record that makes it hard to find a job? (Do not select this category if you are currently incarcerated)
No TANF within 2 years or less
Within two years, will you no longer be eligible to receive Temporary Assistance for Needy Families (TANF) benefits?
Foster Care Youth
Are/were you in the foster care system and are under 24 years old?
Homeless or Runaway Youth
Are you a single parent, unmarried or separated and have primary responsibility for one or more children under age 18, or are you a single, pregnant woman?
Long Term Unemployed
Do you have a low income? Do you receive SNAP, TANF, SSI, or local public assistance? Are you a foster child or homeless?
Migrant and Seasonal Farmworker
(if yes, select a subcategory)
Dislocated Worker
Have you been fired or laid off? Are you unemployed because the place where you worked has closed?
Single Parent or Guardian (or single pregnant woman)
Are you a single parent, unmarried or separated and have primary responsibility for one or more children under age 18, or are you a single, pregnant woman?

How did you hear about Adult Education?

I understand that student information is confidential and will only be used for program administration, research and evaluation purposes.

Applicant Signature *
 Date *

Enter the code shown above. *
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