Adult Education Program Page 2
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3STUDENT CONTACT INFORMATION
Address: _________________________________________________________________________________________
Street Address/ Apartment Number / PO Box
*City
*State
*Zip
*County of residence: _________________________ Email Address: _______________________________________
Phone 1: (______) _________________ Phone 2: (______) _________________ Phone 3: (______) _______________
EMERGENCY CONTACT INFORMATION
Name: ___________________________________________________________________________________________
Last
First
Middle/Former Name
Phone 1: (______) _________________ Phone 2: (______) _________________ Relationship: ____________________
STUDENT STATUS and SPECIAL POPULATIONS
*Labor Force Status:
(select one)
Employed
Employed, but I have received a notice of termination, facility closure, or I am a transitioning service member.
Unemployed and looking for work
If unemployed, have you been unemployed for 27 weeks or longer?
Yes
No
Not working and not looking for work (e.g. homemaker, retired, incarcerated, etc.)
*Do you receive TANF?
Yes
No
If yes, are you within 2 years of exhausting lifetime eligibility?
Yes
No
*Do you or someone in your household receive SNAP benefits (Food Stamps)?
Yes
No
*Special Status Populations:
Yes
No
Low Income
Do you receive SNAP, TANF, SSI, or local public assistance? Are you a foster child or homeless?
Did you provide unpaid services in the home and were dependent on the income of another, but you are no
Yes
No
Displaced Homemaker
longer supported by that income, and are you experiencing difficulty in obtaining or upgrading employment?
Single Parent (or single
Are you a single, separated, divorced or a widowed individual who has primary responsibility for one or more
Yes
No
pregnant woman)
dependent children under the age of 18? Are you a single, pregnant woman?
Have you been terminated or laid off, or received a notice of termination or layoff, or been notified of a
Yes
No
Dislocated Worker
permanent closure of a plant, facility or enterprise where you are employed?
Homeless or
Do you lack a fixed, regular, and adequate nighttime residence? Have you moved in the last 36 months due to a
Yes
No
parent’s employment in seasonal farm work? Are you under 18 and leave home without parent permission?
Runaway Youth
Have you been subject to any stage of the criminal justice process for committing an offense or delinquent act?
Yes
No
Ex-Offender
Do you require assistance in overcoming barriers to employment resulting from an arrest or conviction?
Yes
No
Foster Care
Are you currently in the foster care system or have you aged out of the foster care system?
Seasonal Farmworker (Were you employed for the last 12 months in agricultural or fish farming labor?)
Farmworker (If yes,
Yes
No
Migrant and Seasonal Farmworker (Are you a seasonal farmworker without a permanent residence?)
select a subcategory)
Dependent (Are you a dependent of a seasonal or migrant/seasonal farmworker?)
Do you have attitudes, beliefs, customs or practices that influence a way of thinking, acting, or working that are a
Yes
No
Cultural Barriers
hindrance to employment?
Language spoken at home: ____________________________ Home Country: ____________________________
Special Accommodations Notice (Optional disclosure)
If you have a disability and/or a condition and desire any special accommodation for instruction or testing, it is your responsibility to
notify the program administrative office and provide professional documentation of your disability. A disability is a physical or mental
impairment that substantially limits one or more of a person’s major life activities. If you do not wish to disclose your disability, leave the
question below blank.
*Are you an Individual with a Disability?:
Yes
No If yes, what type?
Learning
Physical
Both
Confidentiality Notice
This adult education program may release your student information for only specific reasons allowed under the Family
Educational Rights and Privacy Act (20 U.S.C. § 1232g; 34 CFR Part 99), such as program evaluation purposes. If you
do not wish this information to be disclosed, please check this box:
*Student’s Signature: ___________________________________________
*Date: __________________
Sign in ink
Technical College System of Georgia, Office of Adult Education, Intake Assessment Form, Effective: July 1, 2017
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