Outreach Student Application Form

OUTREACH STUDENT APPLICATION FORM

Complete each section. Most fields are required.
PERSONAL DATA
I want to take classes at*
I am registering for*

Basic LiteracyEnglish as a Second Language (ESL)Pre-GED/GEDCitizenshipComputer Basics/Keyboarding
Last Name/Surname/Family Name*
First Name/Given Name/Legal Name*
Middle Initial
Gender*

MaleFemaleOther
Address*
Date of Birth*

MonthDayYear
2 digits for Month and Day, 4 digits for the Year
City*
State*
Zip*
Marital Status*

MarriedSingleDivorcedWidowed
# of children living in household under 18*
Numbers only
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Your Email*
example@example.com
Total # of people living in household*
Numbers only
Your First Language*
In your native language, you can*

SpeakReadWrite
Annual Household Income*
Dollar sign goes before the numbers ($1000)
Emergency Contact Name*
First and Last Name
Emergency Contact's Phone Number*
Please enter a valid phone number.
Relation*
How did you hear about us?*

Social MediaFriend/FamilyLibraryNewspaper/Magazine/Special Event/FlyerOther
YOUR GOALS
I want to*

Enter employmentReceive library cardBecame a tutorReceived driver's licenseBecome a U.S. citizenEarn the GEDComplete ESLOther
ETHNICITY
U.S. based Education*

YesNo
Ethnicity*

Hispanic or LatinoNot Hispanic or Latino
Country of Birth*
Race*

WhiteBlack or African AmericanAsianAlaskan NativeNative Hawaiian or Othe Pacific IslanderNative American
Education Level*

Less than 12 gradeHigh school diplomaSome collegeCollege degree
Employment Status*

Full-timePart-timeUnemployedDisabledRetiredNot Labor MarketSeeking WorkDisabled Veteran
Barriers to Employment*

This doesn't apply to me/I'm workingSingle parent/guardianCultural barriersDisabilityDisplaced homemakerLow incomeEnglish language learnerEx-offenderI'll exhaust TANF within 2 yearsFoster care youthHomelessLong-term unemploymentMigrant/Seasonal farmworker
MILITARY
Are you a Veteran of the U.S. Military?*

YesNo
Are you currently active in the U.S. Military or Reserve?*

YesNo
Have you ever been or are you currently on Probation or Parole?*

YesNo
If "Yes" to above, Probation Officer Name and Phone Number
PHOTO RELEASE
Ihereby grant LCFBC permission to use my likeness in a photo, video or other digital media in any and all of its publications, in- cluding web-based productions, without payment, or other consideration. I understand and agree that all photos will become the property of LCFBC and will not be returned. I hereby irrevocable authorize LCFBC to edit, alter, copy, publish or distribute these photos for any lawful purposes. I hereby hold harmless, release and forever discharge LCFBC from all claims, demands and cause of actions which I or my representatives on my behalf may have by reason of this authorization. (Initials)
Initials
I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION , AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF UNDER 18, I HAVE OBTAINED THE REQUIRED CONSENT OF PARENT(S)/GUARDIAN(S) AS EVIDENCED BY THEIR SIGNATURE(S) BELOW.
Applicant Signature*

Clear
ParentGuardian Signature

Clear
Upload Your Photo ID

State ID, Driver License, or Passport ID are acceptable.
Upload ID here*

No selfies
Cancelof
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OUTREACH STUDENT APPLICATION FORM

PERSONAL DATA

YOUR GOALS

ETHNICITY

MILITARY

PHOTO RELEASE

Upload Your Photo ID