WorkReady U Intake Form Adult Education Program - Louisiana Community & Technical College System Student Contact InformationStudent Name First Middle Last Suffix Preferred PronounsHe/HimShe/HerThey/ThemPronouns not listedAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone NumberAlternate Phone NumberEmail Address Emergency Contact InformationEmergency Contact Name First Last Relationship Phone NumberDemographic DetailsSocial Security Number (Do not include dashes) ITIN Date of Birth MM slash DD slash YYYY AgePlease enter a number from 0 to 100.GenderMaleFemaleMarital StatusSingleMarriedDivorcedWidowedOtherAre you a U.S. Citizen?YesNoLanguage Spoken at Home Country of Birth (if not U.S.) Race (select one or more) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White Hispanic, Latina, or Latino?YesNoAre you a parent? (If yes, how many children do your have?)Yes, parent of 1-5 childrenYes, parent of 6-10 childrenYes, parent of 11-13 childrenYes, parent of 14-18 childrenNo, I am not a parentAre you a veteran?YesNoEducation DetailsHighest School Grade Completed at Program EntryNo School Grade CompletedCompleted 1 YearCompleted 2 YearsCompleted 3 YearsCompleted 4 YearsCompleted 5 YearsCompleted 6 YearsCompleted 7 YearsCompleted 8 YearsCompleted 9 YearsCompleted 10 YearsCompleted 11 YearsCompleted 12 YearsHighest Degree or Level CompletedNo Formal SchoolCompleted 1 YearCompleted 2 YearsCompleted 3 YearsCompleted 4 YearsCompleted 5 YearsCompleted 6 YearsCompleted 7 YearsCompleted 8 YearsCompleted 9 YearsCompleted 10 YearsCompleted 11 YearsCompleted 12 Years (HS Diploma Earned)Completed 12 Years (HS Diploma Not Earned)Completed 13 YearsCompleted 14 Years/Associates Degree/Technical DiplomaCompleted 15 YearsCompleted Bachelors DegreeCompleted Beyond Bachelors DegreeHigh School EquivalencyCertificate of Attendance of Completion (HS Only)Post Secondary Degree/Certificate EarnedWhere was your highest level of school completed?Non-US-Based SchoolUS-Based SchoolHave you ever been enrolled in Adult Education before?YesNoAccessibility DetailsSelect all that apply ADHD AUTISM DEAF-BLINDNESS DEAFNESS EMOTIONAL DISTURBANCE HAD AN IEP IN K-12 HARD OF HEARING - INTELLECTUAL DISABILITY MULTIPLE DISABILITIES ORTHOPEDIC IMPAIRMENT OTHER HEALTH IMPAIRMENT SPECIFIC LEARNING DISABILITY SPEECH OR LANGUAGE IMPAIRMENT - TRAUMATIC BRAIN INJURY VISUAL IMPAIRMENT DYSCALCULIA DYSGRAPHIA DYSLEXIA RELATED TO NEUROLOGICAL IMPAIRMENTS Workforce DetailsEmployedFull-timePart-timeEmployed, but received notice of termination or military separation pendingUnemployedNot in the labor force or not available for workNot working, but looking for workRetiredIf you are currently employed, what industry cluster do you work in? If you could get a job or change jobs, what industry cluster would you like to work in? Employer Occupation Have you (or someone in your household) received any of the following in the last six months?TANF (Temporary Assistance for Needy FamiliesSNAP (Supplemental Nutrition Assistance Program) - Food StampsSSI (Supplemental Security Income)State or Local income-based public assistanceHave you received TANF for more than two years in total?YesNoDo any of the following statements apply to you? (Check all that apply) I live in a low-income household. Divide the total annual household income by the number of family members, including yourself, who have lived in your household in the last 6 months. If the average yearly income is $12,750 or less, check this box. I am a former homemaker who is having trouble finding a job or a better job. I am a single parent. I am unmarried or separated from my spouse and have primary responsibility for one or more dependent children under the age of 18, or with another person because I lost my house or apartment. I have a criminal record that makes it hard to find a job. I am in the foster care system (or used to be), and I am less than 24 years old. I am a farmworker. I am a farmworker who has worked in the last 12 months in agriculture or fish farming labor. I am a seasonal farmworker with no permanent residence (migrant). I am a dependent of a farmworker. None of these apply. Goal DetailsWhat is your primary goal? (Choose one)I want to earn a high school equivalency diploma (HiSET, formerly GED)I want to learn EnglishI want to work on my computer skills, financial skills, or health literacyI want to participate in workforce training while working on my reading, writing, and math skillsI want to explore career optionsI want to work on my reading, writing, or math skillsI want to prepare for collegeI want to start college classes while working on my reading, writing, and math skillsI want to start college classes while earning my high school equivalency diploma (HiSET, formerly GED)What other goals would you like to pursue? (optional, choose all that apply) I want to earn a high school equivalency diploma (HiSET, formerly GED) I want to learn English I want to work on my computer skills, financial skills, or health literacy I want to participate in workforce training while working on my reading, writing, and math skills I want to explore career options I want to work on my reading, writing, or math skills I want to prepare for college I want to start college classes while working on my reading, writing, and math skills I want to start college classes while earning my high school equivalency diploma (HiSET, formerly GED) Do any of the following goals apply to you? Improve basic literacy skills Obtain citizenship skills Other personal goals Improve english language skills Achieve work-based project learner goals I want to increase my involvement in my children's education by:Helping more frequently with their schoolworkIncreasing contact with my children's teachers to discuss children's educationBeing more involved in my children's school, such as attending school activities and parent meetings or volunteeringI want to increase my involvement in my children's literacy-related activities by:Reading to childrenVisiting a libraryPurchasing books or magazinesLearning PreferencesWhat types of classes are you interested in? (check all that apply) On Campus: in-person courses where students meet during a specific time as a group Online, Self-Paced: online coursework completed when a learner is ready Online, Cohort: online course where students meet at a specific time as a group Hybrid: some online and some in-person What times are best for you to attend classes? (check all that apply) Morning Afternoon Night Weekend Do you have access to a computer or device to participate in online classes or resources?YesNoDo you have access to the internet at home?YesNoOther DetailsHow did you hear about us? TV Radio Social Media Brochure Career Compass Coach - Recruiter Faculty/Staff Family Member Former Student Friend High School Counselor - Internet Search Newspaper One Stop - American Job Center Unemployment Office Social Service Agency Other Individual with a Disability Notice (optional disclosure): Are you an individual with a disability?YesNoDo not wish to discloseIn the Americans with Disabilities Act of 1990, a disability is defined as a physical or mental impairment that substantially limits one or more of a person's major life activities.Accommodations Agreement Check here to indicate that you understand your responsibility to request accommodations If you have a disability and/or a condition for which you would like special accommodations for instruction or testing, it is your responsibility to notify the program's administrative office and provide professional documentation.SignaturePrinted Name Date MM slash DD slash YYYY Δ
