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Student First Name  *
Student Middle Name 
Student Last Name  *
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Sex  Male  Female

Nurse Licencse Number 

Ethnicity 
Hispanic or Latino Not Hispanic or Latino

Race (mark all that apply)
White
Asian
Black or African American 
Native Hawaiian or other Pacific Islander 
Filipino
American Indian
Alaska Native

Number of years of school completed 

Degree Earned 
None
GED Certificate
High School Diploma 
Technical/Certificate 
AA/AS
4 yr. College Graduate
Graduate Studies
Other

Native Language 
English
Spanish
Vietnamese 
Chinese 
Hmong 
Cambodian 
Tagalog
Korean 
Lao
Russian 
Farsi
Other 

Reason For Enrollment 
  Primary     Secondary    
Improve basic Skills
Improve English skills
HS Diploma/GED
Get a job
Retain job
Enter college or training
Work-based project
Family goal
US Citizenship
Military
Personal goal
None
Other

Personal Status (mark all that apply)
TANF
Other Public Assistance
WIA 1B 
Rehabilitation 
Concurrently enrolled in high school/K-12 
Dislocated Worker
Veteran
Disabled 
Displaced Homemaker
Single Parent 
Bogg Grant
Pell Grant 
GA (Gen Assist.)
SSI 
Bur. Indian Aff. 
Other 

Labor Force Status 
Employed
Unemployed
Not employed and not seeking work  
Retired 

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