IECC Adult Ed Intake Form

IECC Adult Ed Intake Form

Fill out the form carefully for registration
Student Name*

First NameMiddle NameLast Name
Student ID*
Marital Status
Birth Date*

MonthDayYear
Sex at Birth
Gender
*If you, you must provide the card to student services.
YesNo
Native Language
YesNo
Are you a citizen of the United States?
If you are not a US Citizen, Do you hold a permanent resident card?
*If you, you must provide the card to student services.
Are you a Veteran?
*If you, you must provide the card to student services.
American Indian or Alaska NativeAsianBlackNative Hawaiian or Pacific IslanderWhite
Not disabledDocumented Disability as defined by ADAChooses not to disclose
YesNoUnsure
Public Aid ID Number:
Rural AreaUrban area with high unemploymentNeither
Contact Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Student E-mail*
example@example.com
Mobile Number*
Format: (000) 000-0000.
Emergency Contact Name*
Emergency Contact Relation*
Emergency Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Education/Employment
Not in Labor ForceUnemployedEmployed but received notice of termination or military separationEmployed
Hours worked per week?
Employer
Occupation
Work Number
Format: (000) 000-0000.
Agriculture, Food and Natural ResourcesArchitecture and ConstructionArts, A/V Technology and CommunicationsBusiness Management and AdministrationEducation and TrainingFinanceGovernment and Public AdministrationHealth ScienceHospitality and TourismHuman ServicesInformation TechnologyLaw, Public Safety, Corrections, and SecurityManufacturingMarketingScience, Technology, Engineering, and MathematicsTransportation, Distribution, and Logistics
English Language Learner, Low Literacy Levels, Cultural BarriersExhausting TANF within 2 YearsLow IncomeDisplaced HomemakerVeteranSingle ParentIndividual with DisabilityLong-term unemploymentEx-OffenderMigrant/Seasonal WorkerHomeless individual/ Runaway YouthYouth in Foster Care/ Aged out of systemNot Applicable
Title I: Adult, Dislocated Worker, and Youth State ProgramsTitle III: Wagner-Peyser Act Employment ServicesTitle IV: Vocational Rehabilitation Programs
Correctional FacilityCommunity Correctional ProgramOther Institutional Setting
US Based SchoolingNon-US Based Schooling
Month/Year when last enrolled:
Number of School Years Completed:
Last School Attended:
YesNo
YesNo
YesNo
How did you hear about the program?
Yearly household income?
Resident Status:
What is the Highest Degree Earned by Either Parent?*
Earn Illinois High School Diploma with Career Bridge Courses Path AloneEarn Illinois High School Diploma with ICAPS PathwaysEarn Illinois High School Diploma, then pursue College Courses PathEarn Illinois High School Diploma, then focus on Career PathwayEarn Illinois High School Diploma, then pursue College and Career Pathway
What Location do you Plan to Attend Classes?*
Do you plan to Attend Evening or Day Class?*
Signature*

Clear
Date*

MonthDayYear
Date
For Office Use Only:
Program Code(s)/Major(s):
CRN(s), COURSE, NUMBER, SECTION, (1) GRADE - (2) P/F, CREDIT, REPEAT (Y/N)
(Example: 64092, ASE 0804, 40A, 1, 2, N)
Should be Empty:

IECC Adult Ed Intake Form

Contact Information

Education/Employment

For Office Use Only: