Fillable __ I Intake Form of D US Middle (SOWELA Technical Community College)

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__ I Intake Form of D US Middle (SOWELA Technical Community College)

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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
€
Marr
ied
€ Divorced
€ Widowed
€ Other
S
uffix:
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 Hawaii
an
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
H
ave
you
ever
been
enrolled
in
an
Adult
Education Program
before?
□
If
so,
where?
)..,
_________________
___.
I E
nrollment
Details
Current Employment Status:
Empl
oy
ed
Empl
oy
ed
but
re-
ceived notice of
Termination
or
M
ili
tary
Separation
Pe
nd
ing
Unempl
oy
ed
Not
in
the
L
abor
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 receivi
ng
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
Di
ploma
not
earned)
€ Completed
12
Ye
ar
s
(HS
Diploma earned)
€ Completed
13
Years
€ Completed
14
Years
/A
ssoc Deg/Tech
ni
cal Di
ploma
€ 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
Bas
ic Literacy Skill
€ Improve English Language
Sk
ills
€
Obta
in Citizens
hip
S
kill
s
€
Other
Personal Goals
I
Re
f
errals:
Referral
Date:
Referral
To
(WorkReadyU
Program):
€
Avoyelles Parish School System
€
Avoyelles Parish
She
r
iff's
Office
€ Baton Rouge
Community
College
€ Bossier
Pa
rish
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
Cou
ncil
of
SW
LA
€ Livingston Parish School Sy
stem
I
€ Louisiana Delta
Community
College
€
Louisiana
Department
of
Public Safety and Corrections
€
Northshore
Technical Commun
ity
College
€
Nor
t hw est Louisiana Technical College
€
Progressive Education Program, Inc
(PEPI)
€ River Parishes Comm
unity
College
€ Sabine Parish School System
€
South
Lo
uisiana
Community
College
€ St. Bernard Parish School System
€ St.
Cha
rles Parish School System
€ Te
rr
ebonne
Pa
rish
Sc
h
ool
System
€ Volu
nteer
Instructors Teaching Adults (VITA)
€
Winn
Pa
rish School System
€
YMC
A
of
Greater
N.O.
€ Youth Empower
ment
Project - N
OPLAY
7
comment
s:
Comment Date:
Comment:
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__ I Intake Form of D US Middle (SOWELA Technical Community College)

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Completed 17 September 2020

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