Fillable Please&PR INT&AND&fill&in&COMPLETELY & )Returning!Student) Employment!Status:!!!! )Unemployed! ! )Employed,!with!notice!

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Please&PR INT&AND&fill&in&COMPLETELY & )Returning!Student) Employment!Status:!!!! )Unemployed! ! )Employed,!with!notice!

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Please&PR INT&AND&fill&in&COMPLETELY &
!"#$%&'() *&+%#,'-.%&)/01 1)*&+% #,'-.%&)*$)2"34.#"56))))))))))))))))
)New!Student!!!!!!!!!
)Returning!Student)
Last!Name:!___________________________________!First!Name:!______________________________________!MI:!_____!
Birth!Date:!___________________!Ethnicity :!___ ________________________!Native!Language:!_______________________!
Email!Address:!__________________________________________________________________________________________!
Employment!Status:!!!!
)Unemployed! !
)Employed!! !!
)Employed,!with!notice! !
)Not!in!labor!force!
78'-).$)-8")8.98"$-):"'#)%+)$;8%%() ;%,<("-"5=!!_______!!!!!!!7'$)-8"),'>%#.-:)%+):%4#)$;8%%(.&9)%4-$.5")%+)-8")?@A@=)!!!Yes!!/!!No!
B%):%4)8'C")'&:)",<(%:,"&-)D'##."#$=!! (Click all that apply.)!
• Cultu ral!Barriers
• Disabled
• English!Language!Learner
• Displaced!Homemaker
• Ex-Offender
•
Fost er!Care!Youth
• Homeless
•
Long-term!Unemployed
• Low!Income
•
Low!Levels!of!Literacy
• Migrant!Farmwork er
•
Seasonal!Farm worker
• No!TANF!within!2!years
• Single!Parent
78'-)'#"):%4#)'--'.&'D(")9%'($)E.-8.&)-8")<#%9#',):"'#=)
(Mark!1!in!Primary!/!Mark!2!in!Secondary)!!!
_____!Improve!basic!skills! !_____!Improve!English!skills!
_____!H.S.!Diploma/HSE!!!! !!_____!Enter!college!or!training!
_____!Get!a!job!!!!!!!! !!!_____!Retain!a!job!!
_____!Get!a!better!job!!!!!!! !!_____!Work-based!project !!!!!!
_____!Family!goal!!!!!!!! !!_____!U.S.!Citizenship!
_____!Military!!!!!!!! !!_____!Personal!goal!!!!!!
_____!Other!! ! !_____!None!
Are)you)in)any)special)programs?!!( Check all that apply.)!
• EL!Civics!(IELCE) •
Community!Corrections
• Homeless !Program • Fa m ily!Literacy
• Workplace!Ed. • Tutoring
• Distance!Learn ing • Special!Needs
• Alternative!Ed.!(K12) • Non-traditional!Training
• Older!Adults • Carl!P erk ins
B%):%4)#";".C") <4D(.;) '$$.$-'&;") %#) '#").&) '&:) %+)
-8"$") ;'-"9%#."$=! ! (Click all that apply.)
• TANF/Ca lWork s
• Other!Public!Assistance
• Dislocated!Worker
• Veteran
• Other
78'-).$)-8")8.98"$-)5.<(%,')%#)5"9#"")"'#&"5=))/F8";G)%&"6)
___!None!
___!HSE!Certificate!
___!High!School!Diploma!
___!Technical/Certificate!
___!Some!college, !no!degree!
___!A.A./A.S.!Degree!
___!4!yr.!College!Graduate!
___!Higher!than!B.A.!B.S.!
7'$)-8.$)5"9#"")
"'#&"5) %4-$.5")
%+)-8")?@A@=)))))))
Yes!!/ !!No!)
B'-')2"("'$") A-'-","&- ))
NLMAS!adheres!to!the!guidelines!established!by!the!Family!
Education!Rights!and!Privacy!Ac t!(FERPA).!!Any!personally!
identifiable!inf ormation!will!only!be !shared !among !WIOA!partner!
organizations!for!the!purpose!of!measuring!school!performance!
and!assisting !NLMAS!in!qualifying!for!additional!state!and!federal!
funding.!!All!further!disclosure!of!records!is!prohibited.!!For!more!
information,!please!visit:!!
https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html.!
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Please&PR INT&AND&fill&in&COMPLETELY & )ReturningStudent) EmploymentStatus: )Unemployed )Employed,withnotice

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Completed 8 March 2021

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