Registration Form, 2

Holy Cross Family Learning Center

Student Registration Form
Intake Date *

Month Day Year
Date
Enter 0 for SSN if not provided:
SSN
Last Name *
First Name *
Middle Name
Suffix
Student Unique ID
Student External ID
Program must be selected prior to import:
Program
Secondary Program
ESL Student

Yes No
Residence Area
Birthdate *

Month Day Year
Date
Gender *

Male Female
Student Keyword
Are you...?
Is this person Hispanic/Latino *

Yes No
American Indian or Alaska Native *

Yes No
Asian *

Yes No
Black or African American *

Yes No
Native Hawaiian or Other Pacific Islander *

Yes No
White *

Yes No
What is the highest level of education you have completed? Where did you complete that educaton - in the USA or outside the USA?
Highest Ed Level Compl on Entry *
Highest Ed Level Compl on Entry Loc *
Current Level
Employment Status *
Are you currently in any of these categories?

(Under the Workforce Innovations & Opportunities Act, adult education programs are required to serve people who meet the definitions for the following categories. This program will provide services to individuals who do not meet these definitions, but we are required to track those who do. This information is confidential and will only be reported as total number for the state.)
Cultural Barriers

Yes No
Disabled

Yes No
Displaced Homemaker

Yes No
Low Income

Yes No
English Language Learner

Yes No
Ex Offender

Yes No
Exhausting TANF Within Two Years

Yes No
Foster Care Youth

Yes No
Homeless

Yes No
Long Term Unemployed

Yes No
Low Literacy Levels

Yes No
Migrant Farmworker

Yes No
Seasonal Farmworker

Yes No
Single Parent or Guardian

Yes No
Address 1 *
Address 2
Zip Code *
City *
County
State *
Mail Preference
Home Phone

Area Code Phone Number
Mobile Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Email
example@example.com
Contact Preference
Are you receiving...
Public Assistance

Yes No
Are you a...
Dislocated Worker

Yes No
Minor with Adult Status

Yes No
Immigrant

Yes No
Are you in a facility...
Correctional
Institutional

Yes No
Apparent or Disclosed Disability

Yes No
Specific Learning Disability
Funding Stream
Data Sharing Agreed
Should be Empty:

Holy Cross Family Learning Center