Get Student Intake Form 2018-2024

Student Intake Form Comprehensive Adult Student Education System CASES Program Year Site Name Have you been in another adult education program in the past year First Name Yes MI Last Name State Zip Code Maiden/Other Last Name Address City Lives in a Rural Area population 2 500 or less SSN Waiver SSN DOB Gender Primary Phone Alternate Phone Email Student Emergency/Alternative Contact Phone Name Preferred Method of Contact-Check One Text No Student Demographics Are you Hispanic/Latino Choose only one No not Hispanic/Latino Yes Hispanic/Latino a person of Cuban Mexican Puerto Rican Central American or other Spanish culture or origin regardless of race. The following question is about ethnicity not race. No Matter what was selected above please continue to answer the following by marking one or more boxes to indicate what you consider your race to be. American Indian or Alaska Native White Asian Other Black or African American Prefer not to disclose Native Hawaiian or Pacific Islander School Status at Participation In school--post high school Not attending school--did not complete high school Locale of Highest Grade Completed U*S* Based Schooling Non-U*S* Based Schooling Highest School Grade Completed 1st grade 7th grade 2nd grade 3rd grade Last School Attended Highest Education Level Completed Attained a high school diploma Has a disability and attained a certification of attendance/completion as a result of successfully completing an IEP Completed one or more years of postsecondary education Attained a postsecondary technical or vocational certification non-degree Attained an associate degree Attained a bachelor s degree Attained a degree beyond a bachelor s degree No educational level completed Employment Status Not employed Have you been unemployed for 27 or more consecutive weeks Employed Employed but have notice of termination or military separation Not in the labor force Housing Status Confined to a youth correctional facility Confined to an adult correctional facility Living in a community correctional facility Living in other institutional setting not listed group home mental health facility etc* Own/rent residence with friends/family Homeless/runaway youth Dislocated Worker Status Yes local formula Yes statewide Yes both local and statewide Referral None WIOA Title I Adults and dislocated workers Wagner Peyser Vocational Rehabilitation Veterans employment training Trade adjustment assistance Migrant and seasonal farmworkers Seasonal farmworker Dependent of seasonal or migrant and seasonal farmworker Has the student self-disclosed a disability physical or mental Is the student a displaced homemaker Is the student on public assistance Date released from incarceration Does the student perceive any cultural barriers to his or her employment Is the student currently in foster care or aged out of the foster care system. The following question is about ethnicity not race. No Matter what was selected above please continue to answer the following by marking one or more boxes to indicate what you consider your race to be. American Indian or Alaska Native White Asian Other Black or African American Prefer not to disclose Native Hawaiian or Pacific Islander School Status at Participation In school--post high school Not attending school--did not complete high school Locale of Highest Grade Completed U*S* Based Schooling Non-U*S* Based Schooling Highest School Grade Completed 1st grade 7th grade 2nd grade 3rd grade Last School Attended Highest Education Level Completed Attained a high school diploma Has a disability and attained a certification of attendance/completion as a result of successfully completing an IEP Completed one or more years of postsecondary education Attained a postsecondary technical or vocational certification non-degree Attained an associate degree Attained a bachelor s degree Attained a degree beyond a bachelor s degree No educational level completed Employment Status Not employed Have you been unemployed for 27 or more consecutive weeks Employed Employed but have notice of termination or military separation Not in the labor force Housing Status Confined to a youth correctional facility Confined to an adult correctional facility Living in a community correctional facility Living in other institutional setting not listed group home mental health facility etc* Own/rent residence with friends/family Homeless/runaway youth Dislocated Worker Status Yes local formula Yes statewide Yes both local and statewide Referral None WIOA Title I Adults and dislocated workers Wagner Peyser Vocational Rehabilitation Veterans employment training Trade adjustment assistance Migrant and seasonal farmworkers Seasonal farmworker Dependent of seasonal or migrant and seasonal farmworker Has the student self-disclosed a disability physical or mental Is the student a displaced homemaker Is the student on public assistance Date released from incarceration Does the student perceive any cultural barriers to his or her employment Is the student currently in foster care or aged out of the foster care system.