Intake and Enrollment Form
Fill out the form carefully for registration
Student Name
*
First Name
Middle Name
Last Name
E-mail
*
example@example.com
Phone
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
County of Service
*
Please Select
Boyd
Boyle
Carter
Elliott
Garrard
Greenup
Lawrence
Lincoln
Martin
Menifee
Mercer
Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Do you have your GED?
*
YES
NO
Do you have a high school diploma?
*
YES
NO
Last Grade Completed
*
Years Out of School
*
Gender
*
Please Select
Male
Female
N/A
Hispanic Origin
*
YES
NO
Race
*
Please Select
American Indian/ Alaskan Native
Black, or African American
Asian
White
Hawaiian or Pacific Islander
How did you hear about our Services
*
Please Select
Adult Education Rep
Billboard
Career Fair
Direct Mail
Employer
Friend or Family
GED Account of Website
Internet Search
KY CAreer Center
Library
Print (flyer)
Radio
Signage or Road Sign
Social Media
TV
Other
Currently Receiving:
Unemployment
Disability SSI
TANF
SNAP
Medicaid
Wellcare
Other Student Information
Homeless
U.S. Citizen
Veteran
Immigrant
Barriers of Employment
*
YES
NO
Exhausting TANF within 2 Years?
Homeless Participant, Homeless Children and Youths or Runaway Youth?
Single Parent?
Low Income Status?
Cultural Barriers?
Foster Care Youth Status?
Ex-Offender?
Migrant and Seasonal Farmworkers?
Displaced Homemaker?
Long-term Unemployed?
Regular Transportation?
Custody of at Least One Child under the Age of 6?
Individual with a Disability?
Category of Disability (Check all that apply)
Physical/Chronic Health Condition
Vision-related Disability
Cognitive/Intellectual Disability
Physical/Mobility Impairment
Hearing-related disability
Participant did not disclose type of disability
Mental or Psychiatric
Learning Disability
No Disability
Release of Information
*
KAERS*
KY Career Center
KCTCS
Ministerial Association
Prob & Parole
Employer
DCBCS/SNAP
Other
I give the Kentucky Education and Labor Cabinet [Office of Adult Education (OAE)] permission to release my secondary enrollment, GEDTesting Service® information, and employment status to KYAE providers as well as this enrollment information to the KY Center for Statistics,KY Council on Postsecondary Education, the Kentucky Community and Technical College System or any other public postsecondaryinstitution.
*
YES
NO
Signature
Clear
Submit Application
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