i i i i · 2019-06-28 · us citizen: marital status: € single € married € divorced €...
TRANSCRIPT
Date of Birth:
Intake Form
Personal Details:
Intake Date: Fiscal Year: SSN:
Last Name: First Name: Middle Initial:
I
L.I ________ __. Age: US Citizen:
Marital Status: € Single
€ Married
€ Divorced
€ Widowed
€ Other
Suffix:
I Address Information:
Addressl: ._I _________ _.
State:
Active Address: D
I Phone Details:
J.., _______ _. ... I _________ __ L.I _______ _.
Gender: € Male
€ Female
D
Other ID {passport#, visa
info, Etc.:
I .., ________ _.
Address2: ... I ________ __. City:
Zip Code: ._I _____ _.
Address Parish:
Phone Type: € Home
€ Business
Address Type: € Home
€ Business
€ Mailing
Active Phone: D Primary
Phone Number: 1 _
..._ _________ __. € Mobile
Alternate
Phone
Number 1:
Alternate
Phone
Number 2: 1 ..._ _________ _
Phone Type:
Phone Type:
1
€ Other
€ Home Active Phone: D € Business
€ Mobile
€ Other
€ Home Active Phone: D
€ Business
€ Mobile
€ Other
[Emergency Contact:]
Last Name: .. I _________ _. First Name: Relationship: € Father
€ Mother
Phone Number 1: Phone Number € Spouse
I
Friend
Legal Guardian
Other
Email:
Email Address: .. I _____________ _
I
Email Address
Type: Personal
Business
Other
Active Email:
Ethnicity Details:
Is Student Hispanic/Latino: ~
~
I
Check all that are applicable: American Indian or Alaska
Native
Asian
Black or African American
White
Native Hawaiian or Other
Pacific Islander
Program Details: I €
Primary
Program:
Adult Basic Education
Accelerating Opportunity (inactive)
€ Family Literacy
€ Workplace Literacy
Correctional Education Program
(inactive)
€ EL Program (ESL)
EL Civics (inactive)
€ Adult Secondary Education
€ Program for the Homeless
€ Community Corrections Program
€ Other Institutional Programs
€ Distance Education
€ Community Education
€ LA Career Pathway
€ Integrated English Literacy & Civics
Education
€ Integrated Education and Training
Program (IET)
€ Corrections 225
€
€
€
€ €
€
□
€
€
Pathway
Programs:
€
€
€
€
€ €
€
Business
Culinary/ Hospitality
Health Science
Information Technology
Manufacturing
Skilled Craft
Transportation
Other (Specify below)
Other:
Keyword:
{Flags): I
€
€
€
€
--I
ESL Student: □ I I Native Language:
Country of Highest
Education and/or
prior to entering
Adult Ed
I 2
I
I Past Enrollment in Adult Education
Have you ever been enrolled in an Adult Education Program before? □ If so, where? ).., _________________ ___.
I Enrollment Details
Current Employment Status:
Employed
Employed but re
ceived notice of
Termination or
Military Separation
Pending
Unemployed
Not in the Labor
Force
Employer: Date of Employment: Occupation:
€
€
___ ____.I __ I __ I __ I --
€
Long Term Unemployed. > 27
Consecutive weeks.:
D Single Parent: D
€ Public Assistance: D Rural Area: Displaced Homemaker:
Dislocated Worker: D
D D
Cultural Barriers Hindering
Employment: Migrant and Seasonal Farm
worker Status:
€ No
€ Seasonal Farm-
worker
€ Migrant and Sea-
sonal Farmworker
€ A dependent of a
seasonal, or mig-
tant and seasonal
farmworker
In Foster Care Aged Out of Foster Care
Exhausting TANF within 2 years (Part A Title IV of the Social
Security Act.
Individual with
disability:
D
D
□
D
□ € Yes
€ No
€ Not Disclosed
€
Job Corps: Yes
No
Unknown
Low Income: Youth Build: Yes
€ No
€ Unknown
€
€ €
Low levels of Literacy:
Check the box if any of the following conditions apply :
□ D (A) Receives, or in the 6 months prior to application to this program has received, or is a member
of a family that is receiving or in the prior 6 months prior to application to this program has re
ceived:
D (i) SNAP or Louisiana Purchase Card Assistance (ii) TANF Assistance (iii) SSI Assistance or
D (iv) State or local income-based assistance i.e. Louisiana Medicaid, Section 8 Housing, Kinship
Care, Child Care Assistance, LSU Hospital Free Care, or Free Dental Program): or
3
□
Check the box if any of the following conditions apply :
D (B) Is 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
D (C) Is a youth who receives, or is eligible to received a free or reduced price lunch under the Rich
ard B. Russell National School Lunch Act (USC 1751 et seq);
D (D) Is a foster child on behalf of whom State or local government payments are made
D (E} Is an individual with a disability whose own income in the poverty line but who is a member of
a family whose income does not meet this requirement;
D (F) Is a homeless individual or a homeless child or youth or runaway youth
D (G} Is a youth living in a high poverty area.
Ex Offender Status: Tick the checkbox if any of the following conitions are true: Are you are per
son who either
D (A) has been subject to any stage of the criminal justice process for committing a status offense or
delinquent act?
D (B) Requires assistance in overcoming artificial barriers to employment resulting from a record of ar-
rest or conviction for committing delinquent acts, such as crimes against persons, against property,
Homeless Individual, Homeless Children and Youths, or Runaway Youth check if :
D (A} Lacks a fixed, regular, and adequate nighttime residence: this includes an individual who:
(i} is sharing the housing of other persons due to loss of housing, economic hardship, or a similar
reason.
(ii) is living in a motel, hotel, trailer park, or campground due to a lack of alternative adequate
accommodation.
(iii) is living in an emergency or transitional shelter
(iv) is abandoned in a hospital; or
(v) is awaiting foster care placement
D (B) Has a primary nighttime residence that is a public or private place not designed for or ordinarily
used as a regular sleeping accommodation for human beings, such as a car, park, abandoned build
ing, bus or train station, airport or camping ground;
D (c) is a migratory child who in the preceding 36 months was required to move from one school dis
trict to another due to changes in the parent's or parent's spouse's seasonal employment in agri
culture, dairy, or fishing work; or
D (D) is under 18 years of age and absents himself or herself from home or place of legal residence
without the permission of his or her family ( i.e. runaway youth)
4
Adult: Have you received employment or training services through the One•Stop?
D No D Yes, local formula D Yes, statewide D Yes, Both local and statewide
Youth: Have you received employment or training services through the One-Stop?
D No D Yes, local formula D Yes, statewide D Yes, Both local and statewide
Vocational Rehabilitation: Have you received Vocational and Rehabilitation services?
D No D Vocational Rehabilitation D Voe Rehab and Employment, Statewide
D Both, Voe Rehab and Voe Rehab and Employment
Wegner-Peyser Act: Have you received technical training assistance from the one-stop?
0 Yes
School Status at Participation:
□
□
□
□
□ □
{1) Participant has not received a high school diploma or its recognized equivalent and is attending
any secondary school (including elementary, intermediate, junior high school, whether full or part
time or is between school terms and intends to return to school.
(2) Participant has not received a high school diploma or its recognized equivalent and is attending
an alternative high school or an alternative course of study approved by the local educational
agency whether full or part-time, or is between school terms and is enrolled to return to school.
(3) Participant has received a high school diploma or its recognized equivalent and is attending a
post-secondary school or program (whether full or part-time), or is between school terms and is
enrolled to return to school.
(4) Participant is not within the age of compulsory school attendance; and is no longer attending
any school and has not received a high school diploma or its recognized equivalent
(5) Participant is not attending any school and has either graduated from high school or has
attained a high school equivalency
(6) Participant is within the age of compulsory school attendance, but has not attended school for
at least the most recent complete school year calendar quarter and has not received a high school
diploma or its recognized equivalent.
s
Received Training: Yes No Eligible Training Provider-Name
Type of Training Service
Eligible Training Provider-Program of Study I I Eligible Training Provider
CIP Code 1
____________ __,J
..__ _________ ____J
I Disability Details
Disability: € 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 disabilities
€ Speech or Language Impairment
€ Traumatic Brain Injury
€ Visual Impairment
€ Other (Specify Below)
learning
Disabled:
Dyscalculia
Dysgraphia
Dyslexia
Related to Neurological Impairments
Other (Specify Below)
Other:
Other:
I Educational Details: I Highest degree or level
completed:
€ No formal school
€ Completed 1 Year
€ Completed 2 Years
€ Completed 3 Years
€ Completed 4 Years
€ Completed 5 Years
€ Completed 6 Years
€ Completed 7 Years
€ Completed 8 Years
€ Completed 9 Years
€ Completed 10 Years
6
€ €
€
€
€
I
Location: € US Based
€ Non-US Based
€ Completed 12 Years (HS Diploma not earned)
€ Completed 12 Years (HS Diploma earned)
€ Completed 13 Years
€ Completed 14 Years/Assoc Deg/Technical Diploma
€ Completed 15 Years
€ Completed Bachelor Degree
€ Completed Beyond Bachelor Degree
€ High School Equivalency Earned
€ Certificate of Attendance or Completion (HS Only)
€ Post Secondary Degree/Certificate Earned
I
I Goal: I € Improve Basic Literacy Skill
€ Improve English Language Skills
€ Obtain Citizenship Skills
€ Other Personal Goals
I Referrals:
Referral Date:
Referral To (WorkReadyU Program):
€ Avoyelles Parish School System
€ Avoyelles Parish Sheriff's Office
€ Baton Rouge Community College
€ Bossier Parish Community College
€ Catahoula Parish School System
€ Catholic Charities- Archdioceses of N.O.
€ Central Louisiana Technical Community College
€ Delgado Community College
€ East Baton Rouge Parish School Syst em
€ Fletcher Technical Community College
€ Hope House
€ Iberville Parish School System
€ Jefferson Parish School System
€ LCTCS
€ literacy Council of SW LA
€ Livingston Parish School System
I
€ Louisiana Delta Community College
€ Louisiana Department of Public Safety and Corrections
€ Northshore Technical Community College
€ Nort hw est Louisiana Technical College
€ Progressive Education Program, Inc (PEPI)
€ River Parishes Community College
€ Sabine Parish School System
€ South Louisiana Community College
€ St. Bernard Parish School System
€ St. Charles Parish School System
€ Terrebonne Parish School System
€ Volunteer Instructors Teaching Adults (VITA)
€ Winn Parish School System
€ YMCA of Greater N.O.
€ Youth Empowerment Project - NOPLAY
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comments:
Comment Date:
Comment: