Adult Education Program Page 3
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3*Name: _________________________________________________________________________________________
Last
First
Middle/Former Name
Suffix
STUDENT GOALS
*What do you want to achieve by attending the adult education program?
(Completed prior to assessment)
Improve Skills in:
Education Goals:
Career Goals:
Reading
Earn a GED diploma
Find a job
Math
Enroll in a technical college
Keep my job
Writing
Enroll in a private training program
Find a better job
Science
Enroll in a 4-year college
Complete a career assessment
Social Studies
Pursue an apprenticeship
Improve English Language Skills in:
*Integrated English Literacy/Civics Education (IEL/CE):
Achieve citizenship skills
Speaking
Listening
Achieve U.S. citizenship (Georgia goal)
Reading
Increase involvement in community activities
Writing
Vote or register to vote
FOR PROGRAM USE ONLY: The interviewer should complete this section during an initial conference with the
student after his/her pre-assessment.
*1. What is the student’s
primary reason for
enrolling?
*2. What services will
the program provide
the student?
*3. What are the
student’s college,
career, or other
goals?
*4. Did the student
share any personal
barriers that could
affect program
participation? If yes,
please explain.
Additional Notes:
*Student’s Signature:
*Date:
Sign in ink
*Interviewer’s Signature:
*Date:
Sign in ink
Please note: Teachers should conference with the student at least once per quarter. Conference notes must be maintained either in hard copy format in the student
permanent record or in GALIS. More information is available in the Intake Assessment Form Directions and Definitions document.
Technical College System of Georgia, Office of Adult Education, Intake Assessment Form, Effective: July 1, 2017
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