Intake Form

Intake and Enrollment Form

Fill out the form carefully for registration
Student Name*

First NameMiddle NameLast Name
Phone*
E-mail*
Preferred Method of Contact*
Birth Date*

MonthDayYear
County of Residence*
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Highest Grade Completed*
Have you been enrolled in adult education before?*
Gender*
How did you hear about our Services*
Do you own a computer or laptop?*
Race*
How would you rate your digital skills for studying online, working, and accessing services you may need, such as healthcare?
Do you have access to the internet at home?*
Career Development ServiceDisability SSITANF/ KTAPSNAPMedicaidOVRBehavioral Health Prog/SB90CHFS
HomelessU.S. CitizenVeteranImmigrant
Primary Langauge

WIOA Requirements*

Rows	YES	NO
I have been unemployed for 27 weeks (about 6 months) or longer.
I will be exhausting TANF/KTAP within two years.
I am homeless. i live in a motel, hotel, campground, transitional housing, or with another person because I lost my house or apartment.
I am a single parent. I am unmarried or seperated from my spouse and have primary responsibiity for one or more dependent children under the age of 18, ior I am single, prgnant woman.
I live ina low-incolme household, or I receive government assistance (KTAP,SNAP,Medicaid, etc.)
I have cultural practices or dress that can make it hard to get/keep a job.
I am in the foster care system (or used to be).
I have a criminal record that makes it hard to find a job.
I am a seasonal farmworker who has worked in the last 12 months in agriculture or fish farming labor.
I am a seasonal farmworker with no permanent residence (migrant).
I am a displaced homemaker (stay at home parent, provided care for a family member without pay, etc.)
I have unreliable transportation that makes it hard for me to get to work/class.
I am the caretaker for dependant(s) under the age of 13.

Physical/Chronic Health ConditionVision-related DisabilityCognitive/Intellectual DisabilityPhysical/Mobility ImpairmentHearing-related disabilityParticipant did not disclose type of disabilityMental or PsychiatricLearning DisabilityNo Disability
I authorize the Kentucky Education and Labor Cabinet (OAE) to release my information provided within this form to KYAE providers as well to theKY Center for Statistics, KY Council on Postsecondary Education, the Kentucky Community and Technical College System or any other publicpostsecondary institution through data entry into the Kentucky Adult Education Reporting System (KAERS). I understand that this information willbe strictly confidential and only used for program eligibility, program administration, enrollment, evaluation and reporting purposes.*

YESNO
Signature*

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Intake and Enrollment Form