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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
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First Name:
First Name Text Box
Middle Initial:
Student MI Text Box
Last Name:
Last Name Text Box
Preferred First Name:
Preferred Name Text Box
HCC ID Number:
Previous/Alternate Last Name(s):
Alt Name Text Box
Social Security Number:
Soc Sec Text Box
Birthdate:
DOB Calendar
...
Age:
Gender:
Marital Status:
Address:
Address Text Box
Form_Type
City:
City Text Box
State:
Zip:
Zip Text Box
County:
Phone (Cell):
Phone Text Box
Phone (Alternate):
Work Phone Text Box
Email:
Email Text Box
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ETHNICITY/RACE INFORMATION
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Are you a U.S. citizen:
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Yes
No
Are you a permanent resident:
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Yes
No
Do you have a Visa:
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Yes
No
Visa type:
Is English your first language?
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Yes
No
Native Language:
Native Country:
Check the box next to each racial group to which you belong:
Select all that apply:
Ethnicity Check Box List1
No items to display
Which is your primary racial group?
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EDUCATIONAL BACKGROUND INFORMATION
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Predominant School Type:
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U.S. Based Schooling
Non-U.S. Based Schooling
Highest school year completed:
Last School Attended:
Education Last HS Text Box
Month/Year (mm/yy) when last enrolled:
Education Last Enroll MMYY Text Box
Do you have a U.S. high school diploma?
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Yes
No
Do you have a U.S. High School Equivalency credential?
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Yes
No
Highest school year completed:
Last School Attended:
Education Last HS Text Box1 GED Table
Month/Year (mm/yy) when last enrolled:
Education Last Enroll MMYY Text Box1 GED Table
Have you taken the GED test since 2014?
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Yes
No
Have you taken and passed the U.S. Constitution Test?
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Yes, in high school
Yes, in Heartland's GED program
No
Please check any sections of the GED that you have passed:
Sections of GED Passed Check Box List1
No items to display
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EMPLOYMENT INFORMATION
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Employment Status:
Hours worked per week:
Have you received a WIOA Core Partner or One Stop Operator referral?
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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?
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Yes
No
Yes, I receive (check all that apply):
Public Assistance Check Box List1
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What career path interests you?
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ADDITIONAL DEMOGRAPHIC INFORMATION
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From the list below, please indicate all that apply to you:
From the list below, please indicate all that apply to you:
Status Cultural Barriers Check Box
English Language Learner, Low Literacy Levels, and/or have Cultural Barriers to Employment
Status Exhausting TANF Check Box
Exhausting TANF within 2 years
Status Low Income Check Box
Low Income
Status Displaced Homemaker Check Box
Displaced Homemaker
Status Veteran Check Box
Veteran
Status Disability Status Check Box
Documented Disability as defined by ADA
Status Single Parent Check Box
Single Parent
Status Long-term Unemployed Check Box
Long-Term Unemployed
Status Ex-Offender Check Box
Ex-Offender
Status Migrant Check Box
Migrant/Seasonal Farmworker
Status Homeless Check Box
Homeless Person/Runaway Youth
Status Foster Care Check Box
Youth in Foster Care/Aged Out of System
Status In Correctional Facility Check Box
In a Correctional Facility
Status Transportation Assistance Check Box
In Need of Transportation Assistance
Status Not Applicable Check Box
None of the above apply
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EMERGENCY CONTACT INFORMATION
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Emergency Contact Full Name:
Emergency Contact Name Text Box
Emergency Contact Phone Number:
Emergency Contact Phone Text Box
Relationship to Emergency Contact:
Other Relationship:
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OTHER INFORMATION
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How did you hear about this program?
Other:
Which campus would you prefer to attend?
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Normal
Lincoln
Pontiac
Which type of class do you prefer?
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Online Classes
On Campus Classes
When would you prefer to attend classes?
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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:
Signature Other Text Box
Date:
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Submit
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Fiscal year end date
Fiscal YE Calendar
Select a date
...
Fiscal Year Term End