IECC AE Student Intake & Registration Form

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
Student ID:
Semester
Semester Year
Residence Status:
Class Location:
Class Time:
Student Name (Complete Legal Name):

First NameMiddle NameLast Name
Previous Last Name(s) (If applicable):
Sex at Birth
Birth Date

MonthDayYear
Gender:
Parental Status:
Annual Household Income?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County:
Household: (Check One)
Primary Phone Number (Home or Mobile Number)
Format: (000) 000-0000.
Student E-mail
example@example.com
Resides in:
Emergency Contact Name:
Emergency Contact Phone Number:
Format: (000) 000-0000.
Emergency Contact Relation:
Ethnicity: Are you Hispanic or Latino (or Spanish Origin)?
Select one or more of the following Races:
Are you a Citizen of the United States?
Are you a student in Care and/or Homeless?
If you are not a US citizen, do you hold a Permanent Resident Card?
If not, what country?
Are you a Veteran?
Are you disabled?
Receives Public Assistance?
Are you disabled?
Correctional Programs Enrolled in:
How did you hear about the Program?
Education:
Highest Degree Earned:
School Type?
Last High school, city, & State Attended:
Number of School Years Completed?
Month/Year when last enrolled:
US Diploma Upon Enrollment?
If you are a current high school student, provide anticipate HS graduation date:
US HSE Upon Enrollment?
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?
Previous College(s) (College, City, & State):
What is the highest college degree earned by either parent?
Reason for Enrollment:
Employment:
I live out-of-district/out-of-state but work full-time within IECC District 529.
Work-Life (E1): (Check One)
Work Shift(s) if Working (E2):
Employer:
Occupation:
Work Number:
Please enter a valid phone number.Format: (000) 000-0000.
Primary Career Pathway: (Please Check One)
Student Goals:
Barriers to Employment: (Please Check All that Apply)
Resources/Support - What might help you pursue college more easily? (Please Check All that Apply)
Co-Enrolled in other WIOA Title Programs (Please Check All that Apply)
Receives Public Assistance?
Public Aid Number:
If student is under the age of 18, a Parent/Guardian signature is required. Parent/Guardian Signature:
Date

MonthDayYear
Date
Student Signature:
Date

MonthDayYear
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

MonthDayYear
Date
Should be Empty:

Illinois Eastern Community Colleges

IECC Adult Ed Intake Form:

Education:

Employment:

Courses (For Office Use):