Course Registration 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 Service*
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Highest Grade Completed*
Gender*
How did you hear about our Services*
Ethnicity*

Hispanic or LatinoNot Hispanic of Latino
Race*
Do you own a computer or laptop?*
How would you rate your digital skills for studying online, working, and accessing services as healthcare?
Do you have access to the internet at home?*
Currently Receiving:

UnemploymentDisability SSITANFSNAPMedicaidWellcare
Other Student Information

HomelessU.S. CitizenVeteranImmigrant
Native Langauge

Barriers of Employment*

	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 hoem 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 have custody of at least one child younger than 6.

Category of Disability (Check all that apply)

Physical/Chronic Health ConditionVision-related DisabilityCognitive/Intellectual DisabilityPhysical/Mobility ImpairmentHearing-related disabilityParticipant did not disclose type of disabilityMental or PsychiatricLearning DisabilityNo Disability
I hereby give the Kentucky Education and Labor Cabinet, Office of Adult Education (OAE) permission to release: my secondary enrollment, GED Testing Service® information, and employment status to OAE's service providers. I further authorize that the information on the enrollment form may be released to the Kentucky Center for Statistics, Kentucky Council on Postsecondary Education, the Kentucky Community and Technical College System or any other public postsecondaryinstitution.*

YESNO
Signature

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Intake and Enrollment Form