Adult HiSET Application College Transition Programs Student Application College Transition Programs Student ApplicationSocial Security #* Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Phone Type: Mobile Home Date of Birth* MM slash DD slash YYYY Age*Gender* Marital Status:* Single Married Divorced Widowed U.S. Citizen:* Yes No Emergency ContactName* First Last Phone*Relationship of Emergency Contact to Applicant:* EmailEmail* EthnicityEthnicity* Hispanic Non-Hispanic American Indian/Alaska Native Asian Black or African-American White/Caucasian Native Hawaiian or Other Pacific Islander Check ALL that are applicableEmployment DetailsAre you currently employed?* Yes No Place of Employment: What is your position or job title? When did you begin working at your current employer (Start Date)? MM slash DD slash YYYY If you are not employed, are you actively looking for work? Yes No If you are not employed, have you been unemployed for longer than 27 consecutive weeks? Yes No If you are not employed, do you believe cultural barriers are the main reason why you are not employed? Yes No Past Enrollment in Adult Ed ProgramHave you been enrolled in any Adult Education Program before?* Yes No Where have you attended Adult Education (GED/HiSET) classes before?*Current Enrollment DetailsDo you receive any form of public assistance?* Yes No Do you live in a rural area?* Yes No Are you a single parent?* Yes No Do you consider yourself a Displaced Homemaker?* Yes No Do you consider yourself a Dislocated Worker?* Yes No Are you currently in foster care?* Yes No Have you aged out of foster care?* Yes No Have you or any member of your family received, at any point in the last six (6) months, any of the following?* Yes No (a) SNAP or Louisiana Purchase Card Assistance (b) TANF Assistance (c) SSI Assistance (d) State or local income-based assistance (Louisiana Medicaid, Section 8 Housing, Kinship Care, Child Care Assistance, LSU Hospital Free Care, or Free Dental Program)Are you in a family with total family income that does not exceed the higher of the poverty line or 70% of the lower living standard income level?* Yes No Are you currently a youth who receives, or is eligible to receive a free or reduced price lunch under the Richard B. Russell National School Lunch Act (USC 1751 et seq)?* Yes No Are you a foster child on behalf of whom State or local government payments are made?* Yes No Are you an individual with a disability whose own income is at or below the poverty line but who is a member of a family whose income does not meet this requirement?* Yes No Are you a homeless individual or a homeless child or youth OR a runaway youth?* Yes No Are you a youth living in a high poverty area?* Yes No Have you ever been subject to any stage of the criminal justice process for committing a status offense or delinquent act?* Yes No Do you require assistance in overcoming artificial barriers to employment resulting from a record or arrest or conviction for committing delinquent acts, such as crimes against person, crimes against property, status offenses, and/or other crimes?* Yes No Do you lack a fixed, regular, and/or adequate nighttime residence?* Yes No Are you sharing the housing of other persons (not your family members) due to loss of housing, economic hardship, or similar, unlisted reason?* Yes No Are you living in a motel, hotel, or campground due to a lack of alternative adequate accommodations?* Yes No Are you living in an emergency or transitional shelter?* Yes No Is your primary nighttime residence a public or private place not designed or ordinarily used as a regular/common sleeping accommodation for human beings, such as a car, park, abandoned building, bus/train station, airport, or camping ground?* Yes No If you are under 18 years of age, have you left your home or place of legal residence without the permission of your family or legal guardian?* Yes No Have you ever or are you currently receiving employment or transition services through a One-Stop?* Yes No Have you ever or are you currently receiving Vocational and Rehabilitation services?* Yes No Have you ever or are you currently receiving technical training assistance from a One-Stop?* Yes No Goals and Educational ObjectivesWhat courses/classes are you interested in (check all that apply)?* English Language Classes High School Equivalency Class (to prepare for the HiSET) Reading/Math to prepare for the ACCUPLACER, ACT or other standardized test used for college placement Reading/Math to prepare to pass MATH 098, MATH 099, ENGL 099, READ 099, and/or any other remedial/developmental course What is your native language?* If you were not born in the US, what is your native country?* Educational BackgroundWhat is the highest grade or level you completed?* No Formal School 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years (No HS Diploma Earned) 12 Years (HS Diploma Earned) 13 Years 14 Years (Associates Degree/Tech. Diploma) 15 Years High School Equivalency Bachelor’s Degree Beyond Bachelor’s Degree Was the location of the school you last attended located in the United States?* Yes No
