Last Name First Name Email Address Date of Birth Gender Male Female Decline to State Address Street Address City State ZIP Home Phone Mobile Phone Student Status I (Check all that apply) Disabled (enter below) Cultural Barriers Disability Displaced Homemaker Dislocated Worker English Language Learner Ex-Offender Foster Care Youth Homeless Incarcerated Low literacy Low Income Migrant & Seasonal Worker Refugee Seasonal Farmworker Single Parent Veteran Other (enter below) None of the above are applicable Student Status I - Enter Type of Disability if applicable Student Status I - Enter "Other" Status if applicable Student Status II (Check all that apply) CalWORKS CalWORKS will end in 2 years or less Food Stamps/Cal Fresh Job Corps PELL Grant Student Loan SSI/SSA/SDI TANF will end in 2 years WIOA Other (enter below) None of the above are applicable Student Status II - Enter "Other" Status if applicable Labor Force Status (Check ONE only) Employed Unemployed Number of months (enter below) Not employed & not seeking work Going to be laid off Retired Enter Unemployed Number of months (if applicable) Ethnicity (Check all that apply) American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or other Pacific Islander White Education I am attending school now (Check one) Yes No Was the majority of your education earned outside of the United States? Yes No Are you enrolled in High School? Yes No Levels Completed (Check all that apply) No schooling Grades 1 – 5 Grades 6 – 8 Grades 9 – 12, no diploma High School Diploma GED/HSE Certificate High School Certificate of Completion or Attendance Technical Certificate Some college, no degree AA/AS Degree 4 year College Degree Advanced Graduate Studies Advanced Graduate Degree None Was the education above achieved outside the United States? Yes No Income Level Single Person: Maximum annual household income per year including public assistance No income $7,500 $8.500 $9,500 $10,500 $11,500 $12,500 $13,500 $14,500 $15,500+ Income Level Married or Couple: Maximum annual household income per year including public assistance No Income $15,000 $16,000 $17,000 $18,000 $19,000 $20,000 $21,000 $22,000 $23,000 $24,000+ Number of K-12 children in your family: Number of Dependents Native Language (Check one) English Cambodian Chinese Farsi Hmong Korean Lao Russian Spanish Tagalog Vietnamese Other (enter below) Native Language Other than listed above Student Goal for This Year (Check one) Earn high school diploma or equivalency Improve basic skills Improve English Get a job Retain a job Work-based project Military Earn US Citizenship Personal Family goal Enter college or training Get a better job Other (enter below) Student Goal Other than listed above Additional Student Goals for This Year Improve my academic skills Complete a course Get a job Earn more money Earn a high school diploma or equivalent Transition from K-12 to adult school to college Transition from non-credit to credit in college Complete a college certificate, degree, or training program • I acknowledge that a program coordinator will call me after the course has ended to ask about my employment status. Signature Date
