Adult Education Intake Form

Arkansas Adult Education

2023-2024 Intake Form (*Denotes a required field)
Name*

First NameLast Name
SSN
Note: Social security card or acceptable alternative documentation must be presented and viewed by intake staff. If documentation has not been presented, the SSN cannot be recorded in LACES.
Program:

Adult Education - ABE/ASEAdult Education - ESLAdult LiteracyCitizenshipCorrectionsFamily LiteracyIEL/CEIETTransition (ESL>ABE/ASE>Post-Secondary)Workplace ClassesOther
Secondary Program:

Distance LearningHomeless LiteracyIEL/CE (only mark if receiving IEL/CE grant funds)
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMale
Residence Area*

RuralUrban
ESL Student:

YesNo
Complete ONLY if student is 16/17 years old:
Reason Minor Attending Adult Education:

Court OrderedHome SchoolWaived out of High School
Type of Waiver:

Court OrderedHome SchoolWaived out of High School
Last School Attended
Answer "don't know" if school is unknown or out of state.
Score of 535 on TABE level A or D?

YesNo
Citizenship Test Complete

YesNo
Student Keyword:

ABEASEAlternative SentencingAR WorksARS (AR Rehabilitation Services)Distance LearningDSB (Division of Services for the Blind)ESLReentrySNAP E & TTANFOther
Ethnicity: Hispanic/Latino*

YesNo
Race:*

American Indian/Alaskan nativeAsianBlack or African AmericanNative Hawaiian/Pacific IslanderWhiteTwo or more races
Highest Educational Level Completed:*

No SchoolingSecondary School Diloma or CredentialSecondary School Alternative (i.e. GED)Some postsecondary, no degree/diplomaPostsecondary or professional degreeunknownGradeGrade (no Diploma)
Last grade completed blanks Grade blank No Diploma (secondary school)
Location:*

US Based SchoolingNon-US Based Schooling
Last Month/Year Attended
MM/YYYY
Employment Status at Program Entry:*

Employed Full-TimeEmployed Part-TimeUnemployedNot Looking for WorkEmployed with Separation NoticeUnavailable for WorkRetired
Barriers to Employment:

YesNo
If yes, check all that apply:

Cultural BarriersDisabledDisplaced HomemakerLow IncomeEnglish Language LearnerEx-OffenderExhausting TANF in 2 YearsFoster Care YouthHomelessLong Term UnemploymentLow Literacy LevelsMigrant FarmworkerSeasonal FarmworkerSingle Parent/Guardian
Military Service Experience:

YesNo
Notified of Selective Service Obligation:

YesNoNot Applicable
This 18-25-year-old male has been made aware of his obligation to register with the U.S. Selective Service System and has been made aware of how to register. https://www.sss.gov/RegVer/wfRegistration.aspx
Which of the following do you have at home so we can contact you and/or connect you to services?

Computer with CameraComputer without CameraWebcamHeadset with MicrophoneMobile PhoneHome PhoneInternet AccessPrinterScanner
Address*

Street Address Line 2

CityState / Province

Zip
City*
County*
State*
Phone
Cell Phone
Phone
Home
Email
example@example.com
Social Media (Facebook/Instagram, etc.)
Contact preference
Emergency Contact Name
Emergency Contact Phone
Correctional

NoYesYes, CommunityYes, CountyYes, StateYes, Federal
Inmate #
Institutional

NoYes
Apparent or Disclosed Disability:

YesNo
Specific Learning Disability:

Yes, Disclosed/ObservedYes, DocumentedNo
Data Sharing (How Adult Education gets funded):

YesNo
Country of Birth
First/Native Language
How did the participant learn this program?

Friend or family memberNewspaper or magazinePamphlet or brochureEmployerRadioTelevisionWebsiteSocial MediaOther
Referring Agency:

American Job Center (AJC)Arkansas Rehabilitation Services (ARS)Career Pathways Initiative (CPI)Community-based literacy organizationDepartment of Corrections (DOC)Department of Health (DOH)Department of Human Services (DHS)Division of Services for the Blind (DSB)Division of Workforce Services (DWS)Transitional Employment Assistance (TEA)Supplemental Nutrition Assistance Program (SNAP)Faith Based organizationNoneOther
Optional Additional Information: (Check all that Apply)

Driver's LicenseReliable TransportationRegistered To Vote
Arkansas Adult Education provides equal educational opportunities to all students without regard to race, color, sex, gender identity, sexual orientation, age, religion, national origin, ancestry, or handicap.

No otherwise qualified disabled individual shall, solely by reason of such disability, be excluded from the participation in, be denied the benefits for, or be subjected to discrimination in programs or activities sponsored by a public entity.
Data Sharing Agreement (must be signed and marked in LACES in order to be Data Matched)

I give permission for the information collected in the Arkansas Adult Education Data Management System to be used in data sharing within the Arkansas Adult Education Division, and with the Arkansas Department of Workforce Services and the Arkansas Department of Higher Education.
Print Student Name*
Student Signature*

Clear
Date

MonthDayYear
Date
Appendix A

Arkansas Adult Education/Literacy Learning Disabilities Planning & Policy
AUTHORIZATION FOR RELEASE OF STRICTLY CONFIDENTIAL INFORMATION TO LOCAL STAFF OR VOLUNTEERS

I give my permission to release information contained in the document(s) indicated below: Please date, initial, and type "yes" or "No" in the appropriate boxes below.

	Date	Initials	Yes or No
Learning Needs Assessment
Current Intake Form
School Records
Other Records

School records from
Other records from

I give permission to release the information contained in the documents indicated above to the following individuals for educational or assessment purposes: If the same information can be made available to several staff people, please list their names below. Then date, initial, and type "yes" or "no" in the appropriate individuals box.

	Date	Initials	Yes / No
Staff Member 1
Staff Member 2
Staff Member 3
Staff Member 4
Staff Member 5

Permissions:

I give permission to release the information contained in the documents indicated above to the following individuals for educational or assessment purposes: This release is valid for one year from the date of my signature or until it is revoked in writing, whichever occurs first. This release has been read out loud to me and I understand its contents.
Name
Print
Signature

Clear
Date

MonthDayYear
Date
Release of Confidential and/or Academic Information
This release is valid from the date of signature until(Ending Date) or until cancelled by the undersigned in writing. I understand that my participation in GED Testing will be kept confidential and will not be used in any media manner other than stated above without my consent.

This release form has been read and reviewed with me, and I understand its contents.
I, blanks (student name), authorize EACC Adult Education to use my name and/or photo in the following manner:

Initial below if you agree:

	Initials
Graduation Packet, mailings, programs, news release, and/or booklet
Newsletter
Television
Videotaping
Photographing
Radio
Social Media
Other
All Listed Above

This release is valid from the date of signature until blanks (Ending Date) or until canceled by the undersigned in writing. I understand that my participation in GED® Testing will be kept confidential and will not be used in any media manner other than stated above without my consent.
This release form has been read and reviewed with me, and I understand its contents.
(Student Signature)

Clear
(Guardian's Signature)

Clear
(Date)

MonthDayYear
Date
Address

(Street Address/P.O. Box)

Street Address Line 2

(City)(State)

(Zip)
After submitting this form, call (870)-633-4480 ext. 310 for scheduling.
Please upload a picture of your driver's license here:

Cancelof
Please upload a picture of your Social Security Card here:

Cancelof
Should be Empty:

Arkansas Adult Education

Complete ONLY if student is 16/17 years old:

Data Sharing Agreement (must be signed and marked in LACES in order to be Data Matched)

Appendix A

Permissions:

Release of Confidential and/or Academic Information

After submitting this form, call (870)-633-4480 ext. 310 for scheduling.