Adult Education Intake Form

Adult Education Intake Form

Site Name / NRS Registration Type
☐AE ☐ESL ☐IELCE / Region
Date of Enrollment:

Personal Information

*First Name: / Middle Name: / *Last Name:
*Date of Birth: ______/______/______
Month Day Year / *Gender: ☐ Female ☐ Male
*Social Security Number (SSN) :

Contact Information

*Address: / *Primary Phone:
( ) / *Emergency Contact:
( )
*City: / *State: / Other Contact :
( )
*County: / *Zip: / E-mail:

Student Demographics

Ethnicity & Race (select any that apply)
☐ Hispanic / Latino
☐American Indian / Alaska Native
☐ Asian
☐ Black/ African American
☐ Native Hawaiian / Other Pacific Islander
☐ White
☐ Two or More Races /

Employment Status at Program Entry (select one)

☐ Employed
☐ Employed: Notice of termination/ Military Separation
☐ Not In Labor Force
☐ Unemployed
Highest Grade Completed ☐ U.S. ☐ Non-U.S. .
(select one)
☐No Schooling
☐Attended school, but no diploma:______
(Indicate highest grade level Completed)
☐Achieved High School Diploma
☐Achieved High School Equivalency (GED)
☐Completed some College
☐Associate’s Degree
☐Bachelor’s Degree
☐Beyond Bachelor’s Degree /

Other Information(select all that apply)

☐Displaced Homemaker
☐English Language Learner, low levels of literacy, facing cultural barriers
☐Exhausting TANF within 2 years
☐Ex-Offender
☐Homeless Individual and/ or Runaway Youth
☐Long- Term Unemployed 27+ consecutive weeks
☐Low Income
☐Migrant and Seasonal Farmworker
☐Individual with a Disability
☐Single Parent (including single pregnant women)
☐Foster Care/ Aged out system

-continued on back-

Native Language (select one)
☐ English
☐ Chinese
☐ German
☐ Somali
☐ Cambodian
☐ French
☐ Spanish
☐ Korean
☐ Other /

On Public Assistance(select all that apply)

☐Unemployment
☐Food Stamps
☐Social Security
☐WIC
☐Other______
Learned about this Program? (select One)
☐Friend or Family member
☐Online/Internet (website, search, social media, etc)
☐Newspaper or Magazine
☐Pamphlet or brochure
☐Employer
☐Radio or TV
☐Court or Court Order
☐Catalog
☐College Advisor
☐Other______
☐None / Referred by Agency?(select One)
☐Career Pathways
☐Community based literacy organization
☐Department of Correction
☐Department of Health & Welfare
☐Department of Labor
☐Employment Training
☐Even Start/ Head Start
☐Faith-based Organization
☐Jail
☐Juvenile Detention
☐Local public school
☐One-Stop/Workforce Center
☐Vocational Rehabilitation
☐Other______
☐None
I give permission for the information collected in the Idaho Management and Accountability System (IMAS) to be used for the purposes of client referrals to WIOA partners, and in data sharingfor program reporting purposes within the Division of Career Technical Education, and GED Testing Services. I understand the Adult Education program will protect my confidentiality and at no time will this information be given to any other party without my express written consent.
Student Signature: / Date:
For Office Use Only(please initial)
Intake Person: / Notes/Comments:
Data Entry Date:
Approval Date:
Separation Date:
IMAS Student ID #:

Form Last Updated July 2018