Illinois Eastern Community Colleges
Student information & Registration Form | www.iecc.edu | Course Enrollee
IECC Adult Ed Intake Form:
Fill out the form completely for registration
Semester
*
Summer
Fall
Spring
Semester Year
*
Class Location:
*
Please Select
FCC
LTC
OCC
WVC
Lawrenceville
Newton
Flora
Online
Class Time:
*
Please Select
AM
PM
Online
Student ID:
*
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
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
Please select a year
2025
2024
2023
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
Student Name (Complete Legal Name):
*
First Name
Middle Name
Last Name
Previous Last Name(s) (If applicable):
Sex at Birth
Please Select
Male
Female
N/A
Gender:
Man (1)
Woman (2)
Trans Man (5)
Trans Woman (6)
Non-Binary (8)
Not listed or Unknown (7)
Household: (Check One)
Please Select
Single (S)
Married (M)
Divorced (D)
Separated (P)
Widow/Widower (W)
Annual Household Income?
Parental Status:
1. Student is not a parent
2. Single-Parent Student (includes pregnant individuals)
3. Married-Parent Student (includes pregnant individuals)
Residence Status:
In-District 529 (1)
Out-of-District (3)
Out-of-State (5)
Foreign (7)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County:
Resides in:
Rural Area
Urban area with high unemployment
Neither
Unsure
Primary Phone Number (Home or Mobile Number)
Student E-mail
*
example@example.com
Emergency Contact Name:
*
Emergency Contact Phone Number:
*
Emergency Contact Relation:
*
Are you a student in Care and/or Homeless?
1. Homeless - Lacking a fixed, adequate nighttime residence
2. Student in Care - Any person who was/is under DCFS custody
3. Homeless and Student in Care
Not applicable
Ethnicity: Are you Hispanic or Latino (or Spanish Origin)?
Yes
No
Select one or more of the following Races:
Asian
Native American Indian/ Alaskan
Black/ African American
Middle Eastern or North African
White
Non-Resident
Native Hawaiian/Other Pacific Islander
Are you a Citizen of the United States?
*
Yes
No
If you are not a US citizen, do you hold a Permanent Resident Card?
*
Yes
No
If not, what country?
Are you a Veteran?
*
Not a verteran
Active duty
Veteran of Active Military Service
Are you disabled?
*
Not disabled
Documented disability as defined by ADA
Chooses not to disclose
Receives Public Assistance?
*
Yes
No
Unsure
Are you disabled?
*
Not disabled
Documented disability as defined by ADA
Chooses not to disclose
Correctional Programs Enrolled in:
Please Select
Correctional Facility
Community Correctional Program
Other Institutional Setting
How did you hear about the Program?
Education:
Highest Degree Earned:
A - Associate Degree
B - Bachelor's Degree
C - Certificate
D - Doctoral Degree
G - GED
H - High School Diploman
M - Master's Degree
N - None
O - Other
P - First Professional Degree
School Type?
*
US Based Schooling
Non-US Based Schooling
N/A
Last High school, city, & State Attended:
Number of School Years Completed?
Month/Year when last enrolled:
US Diploma Upon Enrollment?
Please Select
Yes
No
If you are a current high school student, provide anticipate HS graduation date:
US HSE Upon Enrollment?
Please Select
Yes
No
Date Completed HSE (If applicable):
In order to process your Adult Education paperwork as you complete the program, your consent is needed to proceed with enrollment. Do you grant consent for us to obtain your IL HSE test results?
*
Please Select
Yes
No
Previous College(s) (College, City, & State):
What is the highest college degree earned by either parent?
Some college (No credential)
Certificate
Associates (2-year) degree
Bachelors (4-year) degree or higher degree
Parent did not attend college
Unknown
Reason for Enrollment:
1. Prepare for Transfer
2. Improve Skills for a Job
3. Prepare for a Future Job
4. Prepare for GED
5. Personal Interest
6. Unknown/Explore Courses/Career/Other
Employment:
I live out-of-district/out-of-state but work full-time within IECC District 529.
Yes
No
Work-Life (E1): (Check One)
*
Please Select
I am a homemaker/retired/other - Not in Labor Force. (0)
I work More than 30 Hours per Week - (1)
I work Less than 30 Hours per Week - (2)
I am Employed but Received Notice of Termination or Military Separation. (3)
I do not plan to work while in college - Not in the Labor Force. (4)
I am currently unemployed. (5)
Work Shift(s) if Working (E2):
Please Select
I work Day Shift (1)
2nd Shift (2)
3rd Shift (3)
Weekends (4)
Multiple Shifts (5)
N/A
Employer:
Occupation:
Work Number:
Please enter a valid phone number.
Primary Career Pathway: (Please Check One)
Agriculture, Food, and Natural Resources
Architecture and Construction
Arts, A/V Technology and Communications
Business Management and Administration
Education and Training
Finance
Government and Public Administration
Health Science
Hospitality and Tourism
Human Services
Information Technology
Law, Public Safety, Corrections, and Security
Manufacturing
Marketing
Science, Technology, Engineering, and Mathematics
Transportation, Distribution, and Logistics
Student Goals:
English Language Acquisition
Earn Illinois High School Diploma with Career Bridge Courses Path Alone
Earn Illinois High School Diploma with ICAPS Pathways
Earn Illinois High School Diploma, then pursue College Courses Path
Earn Illinois High School Diploma, then focus on Career Pathway
Earn Illinois High School Diploma, then puruse College and Career Pathway
Barriers to Employment: (Please Check All that Apply)
English Language Learner, Low Literacy
Levels, Cultural Barriers (1)
Migrant/ Seasonal Farmer (2)
Low income (3)
Individual with a Disability (4)
Displaced Homemaker (5)
Single Parent (6)
Ex-Offender (7)
Long-term Unemployment (8)
Exhausting TANF within 2 years (9)
Homeless/ Runaway Youth (10)
Youth in Foster Care/Aged Out of System (11)
Veteran (12)
Not Applicable (13)
English is a Second Language (14)
Resources/Support - What might help you pursue college more easily? (Please Check All that Apply)
Child Care While in School (E3-CC)
Single Parent Program Resources (E3 - SP)
Transportation to School (E4 - RIDE)
Work Study or Job Placement Services while in School (E5 - WS)
Job Shadowing Opportunities in my Area(s) of Interest (E5 - JS)
Personal Development Services and Opportunities on Campus (E6 - PD)
Learning Skills Center Support Services/Tutoring (E6 - LSC)
Financial Aid/ Scholarships/ Financial Support (E7 - FA)
No Need for Extra Assistance/Resources at this time.
Other (Please provide information about supports you have used successfully in the past)
Co-Enrolled in other WIOA Title Programs (Please Check All that Apply)
Title I: Adult, Dislocated Worker, and Youth State Programs
Title III: Wagner-Peyser Act Employment Services
Title IV: Vocational Rehabilitation Programs
Receives Public Assistance?
Please Select
Yes
No
Unsure
Public Aid Number:
If student is under the age of 18, a Parent/Guardian signature is required. Parent/Guardian Signature:
Date
-
Month
-
Day
Year
Date
Student Signature:
Date
-
Month
-
Day
Year
Date
Courses (For Office Use):
Program Code(s)/Major(s)
Anticipated Graduation Date:
CRN | Course | Number | Section | 1-Grade, 2-P/F, Credit | Repeat Y/N
CRN | Course | Number | Section | 1-Grade, 2-P/F, Credit | Repeat Y/N
CRN | Course | Number | Section | 1-Grade, 2-P/F, Credit | Repeat Y/N
CRN | Course | Number | Section | 1-Grade, 2-P/F, Credit | Repeat Y/N
CRN | Course | Number | Section | 1-Grade, 2-P/F, Credit | Repeat Y/N
Fee Paying Agency:
Advisor/Instructor Signature:
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: