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
Gender
Is English a Second Language?

YesNo
Native Language
Is the student Hispanic or Latino?

YesNo
Is the student from one or more of the following ethnic groups (required for non-Latino)?

American Indian or Alaska NativeAsianBlackNative Hawaiian or Pacific IslanderWhite
Disability Status:

Not disabledDocumented Disability as defined by ADAChooses not to disclose
Receives Public Assistance?

YesNoUnsure
Public Aid ID Number:
Resides in:

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
Emergency Contact Name
Emergency Contact Relation
Emergency Contact Number
Please enter a valid phone number.
Education/Employment
Employment Status:

Not in Labor ForceUnemployedEmployed but received notice of termination or military separationEmployed
Hours worked per week?
Employer
Occupation
Work Number
Primary Career Pathway:

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
Barriers to Employment (Select All that Apply):

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
Co-Enrolled in other WIOA Title Programs (Select All that Apply):

Title I: Adult, Dislocated Worker, and Youth State ProgramsTitle III: Wagner-Peyser Act Employment ServicesTitle IV: Vocational Rehabilitation Programs
Enrolled In:

Correctional FacilityCommunity Correctional ProgramOther Institutional Setting
School Type?

US Based SchoolingNon-US Based Schooling
Month/Year when last enrolled:
Number of School Years Completed:
Last School Attended:
US HSE Upon Enrollment?

YesNo
US Diploma Upon Enrollment?

YesNo
Consent granted to obtain HSE test results?

YesNo
Courses
How did you hear about the program?
Yearly household income?
Student Goals:

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
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

IECC Adult Ed Intake Form

Contact Information

Education/Employment