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Information provided will be kept confidential in accordance with the Family Educational Rights and Privacy Act of 1974 (P.L. 93-380)
STUDENT INFORMATION
First Name:
Middle Initial:
Last Name:
Preferred First Name:
HCC ID Number:
Previous/Alternate Last Name(s):
Social Security Number:
Birthdate:
...
Age:
Gender:
Marital Status:
Address:
Form_Type
City:
State:
Zip:
County:
Phone (Cell):
Phone (Alternate):
Email:
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ETHNICITY/RACE INFORMATION
Are you a U.S. citizen:
Yes
No
Are you a permanent resident:
Yes
No
Do you have a Visa:
Yes
No
Visa type:
Is English your first language?
Yes
No
Native Language:
Native Country:
Check the box next to each racial group to which you belong:
Select all that apply:
No items to display
Which is your primary racial group?
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EDUCATIONAL BACKGROUND INFORMATION
Predominant School Type:
U.S. Based Schooling
Non-U.S. Based Schooling
Highest school year completed:
Last School Attended:
Month/Year (mm/yy) when last enrolled:
Do you have a U.S. high school diploma?
Yes
No
Do you have a U.S. High School Equivalency credential?
Yes
No
Highest school year completed:
Last School Attended:
Month/Year (mm/yy) when last enrolled:
Have you taken the GED test since 2014?
Yes
No
Have you taken and passed the U.S. Constitution Test?
Yes, in high school
Yes, in Heartland's GED program
No
Please check any sections of the GED that you have passed:
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EMPLOYMENT INFORMATION
Employment Status:
Hours worked per week:
Have you received a WIOA Core Partner or One Stop Operator referral?
Yes
No
What is the name of the referring WIOA Core Partner or One Stop Operator?
Do you receive any Public Assistance?
Do you receive any Public Assistance?
Yes
No
Yes, I receive (check all that apply):
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What career path interests you?
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ADDITIONAL DEMOGRAPHIC INFORMATION
From the list below, please indicate all that apply to you:
From the list below, please indicate all that apply to you:
English Language Learner, Low Literacy Levels, and/or have Cultural Barriers to Employment
Exhausting TANF within 2 years
Low Income
Displaced Homemaker
Veteran
Documented Disability as defined by ADA
Single Parent
Long-Term Unemployed
Ex-Offender
Migrant/Seasonal Farmworker
Homeless Person/Runaway Youth
Youth in Foster Care/Aged Out of System
In a Correctional Facility
In Need of Transportation Assistance
None of the above apply
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EMERGENCY CONTACT INFORMATION
Emergency Contact Full Name:
Emergency Contact Phone Number:
Relationship to Emergency Contact:
Other Relationship:
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OTHER INFORMATION
How did you hear about this program?
Other:
Which campus would you prefer to attend?
Normal
Lincoln
Pontiac
Which type of class do you prefer?
Online Classes
On Campus Classes
When would you prefer to attend classes?
9 AM - 1 PM
5 PM - 9 PM
No Preference
By typing my name below, I confirm that all information provided is accurate and I can provide documentation if necessary.
Signature:
Date:
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Fiscal year end date
Select a date
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Fiscal Year Term End