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Form_Type
AELP - Advanced English for non-English speakers
FESL - Basic English for non-English speakers
HSE - NORMAL CAMPUS High School Equivalency (GED)
HSE - LINCOLN CAMPUS High School Equivalency (GED)
HSE - PONTIAC CAMPUS High School Equivalency (GED)
STUDENT INFORMATION
Name (Last)
(First)
Init
HCC ID#
Email
Previous/Alternate Last Name(s)
Preferred Name
Social Security Number
Gender
Phone (home)
Phone (work)
Birthdate
...
Age
Marital Status
Address
Apartment
City
State
Zip
County
Other County
Is English your first language?
Yes
No
Native Language
Native Country
Visa Status
Other Visa Status
What is your primary racial group?
Select all that apply:
Select all that apply:
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CLASS PREFERENCES
Which class schedule would you prefer?
AM
PM
Which would you prefer?
Online Class
On Campus Class
EMERGENCY CONTACT INFORMATION
Name:
Relationship:
Relationship Other
Phone Number:
EDUCATIONAL BACKGROUND INFORMATION
School Type US Based?
Yes
No
Highest Grade Completed:
Last U.S. High School Attended:
Last Enrolled: MM/YY
US High School Equivalency?
Yes
No
US Diploma?
Yes
No
Have you taken and passed the Constitution Test?
Have you taken the GED test after 2014?
Yes
No
Please check any sections of the GED that you have passed:
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OTHER INFORMATION
Employment Status
Employer Name
Hours worked per week
Referral from WIOA Core Partner or One Stop
Yes
No
If Yes, Name of referring partner/One Stop
Public Assistance:
Public Assistance:
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* I understand that by marking the Disability box I give my permission for the ADA Coordinator to contact DSS and my instructor.
Disability Status
Do you need Transportation Assistance?
Yes
No
Do you need Childcare?
Yes
No
How did you hear about this program
Other:
What career path Interests you?
Please identify any barriers to employment that you face, regardless of employment status. Please select all that apply:
Please identify any barriers to employment that you face, regardless of employment status. Please select all that apply:
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Please check all that apply:
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By typing my name, I verify that all information provided is accurate and I can provide documentation if necessary.
Signature:
Date:
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Authorization of Release of Information
Name (Last):
(First) :
Middle:
PHOTO RELEASE
No, please do not use my photo
Yes, my photo may be used
HSE TEST RELEASE
I hereby agree to release my HSE (GED, HiSet, TASC) scores to the Adult Education department at Heartland Community College. These scores will be kept strictly confidential.
No, please do not release my test scores.
Yes, my scores may be released.
ACADEMIC RECORD RELEASE
No, please do not release my academic information to anyone.
Yes, please release the following academic information:
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Please Specify:
I release the above information to the following:
Name (other than self)
Mc Lean County Court Services
Logan County Court Services
Livingston County Court Services
Student Access and Accommodations Services (SAAS) at Heartland Community College
Other
Name:
Agency:
Phone:
Signature:
Date:
Select a date
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