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I want to submit the form for...
Form_Type
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Form_Type Choice
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)
Last Name Text Box
(First)
First Name Text Box
Init
Student MI Text Box
HCC ID#
Email
Email Text Box
Previous/Alternate Last Name(s)
Alt Name Text Box
Preferred Name
Preferred Name Text Box
Social Security Number
Soc Sec Text Box
Gender
Phone (home)
Phone Text Box
Phone (work)
Work Phone Text Box
Birthdate
DOB Calendar
...
Age
Age Text Box
Marital Status
Address
Address Text Box
Apartment
Apartment Text Box
City
City Text Box
State
Zip
Zip Text Box
County
Other County
Is English your first language?
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English first Choice
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:
Ethnicity Check Box List1
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CLASS PREFERENCES
Which class schedule would you prefer?
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Class Schedule Pref Time Choice
AM
PM
Which would you prefer?
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Class Schedule Pref Type Choice
Online Class
On Campus Class
EMERGENCY CONTACT INFORMATION
Name:
Emergency Contact Name Text Box
Relationship:
Relationship Other
Phone Number:
Emergency Contact Phone Text Box
EDUCATIONAL BACKGROUND INFORMATION
School Type US Based?
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School Type US Based Choice
Yes
No
Highest Grade Completed:
Last U.S. High School Attended:
Education Last HS Text Box
Last Enrolled: MM/YY
Education Last Enroll MMYY Text Box
US High School Equivalency?
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US High School Equivalency Choice
Yes
No
US Diploma?
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US Diploma Choice
Yes
No
Have you taken and passed the Constitution Test?
Have you taken the GED test after 2014?
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GED after 2014 Choice
Yes
No
Please check any sections of the GED that you have passed:
Sections of GED Passed Check Box List1
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OTHER INFORMATION
Employment Status
Employer Name
Employer Name Text Box
Hours worked per week
Hours worked week Text Box
Referral from WIOA Core Partner or One Stop
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Referral from WIOA or One Stop Choice
Yes
No
If Yes, Name of referring partner/One Stop
Public Assistance:
Public Assistance:
Public Assistance Check Box List1
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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?
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Transportation Assistance Choice
Yes
No
Do you need Childcare?
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Need Childcare Choice
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:
Barriers faced Check Box List
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Please check all that apply:
Institutional Setting Check Box List
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By typing my name, I verify that all information provided is accurate and I can provide documentation if necessary.
Signature:
Signature Other Text Box
Date:
Signature Other Date Calendar
Select a date
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Authorization of Release of Information
Name (Last):
(First) :
Middle:
PHOTO RELEASE
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Photo Release Choice
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.
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Testing Release Choice
No, please do not release my test scores.
Yes, my scores may be released.
ACADEMIC RECORD RELEASE
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Academic Release Choice
No, please do not release my academic information to anyone.
Yes, please release the following academic information:
Academic Release Boxes Check Box List1
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Please Specify:
I release the above information to the following:
Release Name Check Box
Name (other than self)
Release Mc Lean Co. CS Check Box
Mc Lean County Court Services
Release Logan Co. CS Check Box
Logan County Court Services
Release Livingston Co. CS Check Box
Livingston County Court Services
Release SAAS Check Box
Student Access and Accommodations Services (SAAS) at Heartland Community College
Release Other Check Box
Other
Name:
Agency:
Phone:
Authorize Release Check Box
Understand Release Check Box
Signature:
Signature Authorize Text Box
Date:
Signature Authorize Date Calendar
Select a date
...
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Submit
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Fiscal year end date
Fiscal YE Calendar
Select a date
...
Fiscal Year Term End