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Student First Name  *
Student Last Name  *
Address  *
City  *
State  *
ZIP  *
 
Home Phone  *
Work Phone 
 
Email  *
Confirm Email  *
 
Sex  Male  Female*

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 

Annual Income*
Single person and income below $7,500 per year (add $1,000 for each dependant child)
Married and combined income is below $15,000 per year (add $1,000 for each dependant child)
None of the above

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