2023-2024 Adult Education Intake Form

Arkansas Adult Education

2023-2024 In-Take Form
Date

MonthDayYear
Date
Start Time

Hour Minutes

AM/PM Option
End Time

Hour Minutes

AM/PM Option
Intake Hours
Staff
Site/Location
LEA Program
Student Section
( * = required feilds )
Name*

First NameLast Name
Middle Name
Suffix
SSN*
For security, enter "000-00-0000" in this blank.
Note: Social security card or acceptable alternative documentation must be presented and viewed by intake staff. If documentation has not been presented, the SSN cannot be recorded in LACES.
Program*

Adult Education - ABE/ASEAdult Education - ESLAdult LiteracyCitizenshipCorrectionsFamily LiteracyIEL/CEIETOtherTransition (ESL to ABE/ASE to Post-Secondary)Workplace Classes
Secondary Program

Distance LearningHomeless LiteracyIEL/CE (only mark if receiving IEF/CE grant funds)
Accelerated Opportunities

YesNo
WAGE Program:

YesNo
ESL Student

YesNo
Residence Area:*

RuralUrban
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMale
Waiver for 16/17-year-old (place copy in student's folder. This only applies to 16/17 year old students.)

Court OrderHome SchoolPublic School
16/17 year old - Last School Attended
Citizenship Test Completed

NoYes
Score a 535 on TABE Level A or D?

YesNo
Student Keyword*

ABEARS (AR Rehabilitative Services)ReentryASEAlternative SentencingDSB (Division of Services for the Blind)Distance LearningSNAP/E&TTANFAR WorksESLOther:
Ethnicity: Hispanic/Latino*

YesNo
Race*

American Indian/Alaskan NativeNative Hawaiian/Pacific IslanderAsianBlack or African-AmericanWhiteTwo or More Race
Highest Educational Level Completed at Program Entry:*

No SchoolingNo diplomaSecondary School Alternative (i.e. GED)Some postsecondary, no degree/diplomaPostsecondary or professional degreeSecondary School Diploma or CredentialUnknown
Highest Grade Completed:*
Location*

US Based SchoolingNon-US Based Schooling
Last Month/Year Attended
Employment Status at Program Entry*

Employed Full-TimeUnavailable for WorkEmployed Part-TimeRetiredUnemployedEmployed with Separation NoticeNot Looking for Work
Barriers to Employment*

YesNo
If yes, check all that apply

Cultural BarriersFoster Care YouthDisabledHomelessDisplaced HomemakerLong Term UnemploymentLow IncomeLow Literacy LevelsEnglish Language LearnerMigrant FarmworkerEx-OffenderSeasonal FarmworkerExhausting TANF in 2 YearsSingle Parent/Guardian
This 18-25-year-old male has been made aware of his obligation to register with the U.S. Selective Service System and have been made aware of hot ot register. https://www.sss.gov/RegVer/wfRegistration.aspx
Military Service Experience

YesNo
Notified of Selective Service Obligation*

YesNoNot Applicable
Which of the following do you have at home so we can contact you and/or connect you to services? Mark all that apply.

Computer with CameraComputer without CameraWebcamHeadset with MicrophoneMobile PhoneHome PhoneInternet AccessPrinterScanner
Address*

Address

Street Address Line 2

CityState / Province

Zip
City*
County*
State*
Phone*
Cell Phone:*
Email Address*
example@example.com
Social Media (Facebook/Instagram etc.)
Contact preference*
Emergency Contact (name & phone)*
Correctional*

NoYesYes, CommunityYes, StateYes, CountyYes, Federal
Inmate #
Institutional*

NoYes
Apparent or Disclosed Disability

YesNo
Specific Learning Disability

Yes, Disclosed/ObservedYes, Documented
Notes
Note: If a disability is disclosed, please have the student sign the Authorization for Release of Strictly Confidential Information to Local Staff or Volunteers form and keep in a separate locked file. (Appendix A)
Arkansas Adult Education provides equal educational opportunities to all students without regard to race, color, sex, gender identity, sexual orientation, age, religion, national origin, ancestry, or handicap.

No otherwise, qualified disabled individual shall, solely by reason of such disability, be excluded from the participation in, be denied the benefits for, or be subjected to discrimination in programs or activities sponsored by a public entity.

Data Sharing Agreement (must be signed and marked in LACES in order to be Data Matched)

I give permission for the information collected in the Arkansas Adult Education Data Management System to be used in data sharing within the Arkansas Adult Education Division, and with the Department of Workforce Services and the Arkansas Department of Higher Education.
Do you agree to share your data?

YesNo
Type Student Name*
Please sign to approve data sharing

Clear
Date*

MonthDayYear
Country of Birth*
First/Native Language*
How did the participant learn about this program?*

Friend or family memberNewspaper or magazineTelevisionWebsitePamphlet or brochureEmployerRadioSocial MediaOther:
Referring Agency:*

American Job Center (AJC)Arkansas Rehabilitation Services (ARS)Career Pathways Initiative (CPI)Community-based literacy organizationDepartment of Corrections (DOC)Department of Health (DOH)Department of Human Services (DHS)Division of Services for the Blind (DSB)Division of Workforce Services (DWS)Transitional Employment Assistance (TEA)Supplemental Nutrition Assistance Program (SNAP)Faith Based OrganizationNoneOther:
Driver's License

YesNo
Reliable Transportation

YesNo
Registered to Vote

YesNo
Additional notes/comments (i.e. support services needed or requested, attendance at other adult education program, program interests, etc.)
Appendix A Arkansas Adult Education/Literacy Learning Disabilities Planning & Policy

AUTHORIZATION FOR RELEASE OF STRICTLY CONFIDENTIAL INFORMATION TO LOCAL STAFF OR VOLUNTEERS

I give my permission to release information contained in the document(s) indicated below: Please date, initial and check ]the appropriate items below.

I give permission to release the information contained in the documents indicated below to the following individuals for educational or assessment purposes:

If the same information can be made available to several staff people, please list their names below. Then date, initial and check ] the appropriate individuals. If different information is going to various individuals, use separate forms.

I give permission to release the information contained in the documents indicated below to the following individuals for educational or assessment purposes:

This release is valid for one year from the date of my signature or until it is revoked in writing, whichever occurs first. This release has been read out loud to me and I understand its contents.

Appendix A Authorization*

	Yes	No
Learning Needs Screening
Current Intake Form
School Records Form
Other Records From

Faculty/Staff Given Permission*

	Yes	No
Employee 1
Employee 2
Employee 3
Employee 4
Employee 5
Employee 6
Employee 7
Employee 8

Name*
Signature*

Clear
Date

MonthDayYear
Signature of staff person releasing the information:
Name
Signature

Clear
Date

MonthDayYear
Release of Confidential and/or Academic Information

I authorize EACC Adult Education/Literacy Center to use my name and/or photo in the following manner:
Name

First NameLast Name
Program Name
(select forms of use below if you agree)

NewsletterGraduation Packet, mailings, programs, news release, and/or bookletTelevisionVideotappingPhotographingRadioSocial MediaOtherAll listed above
This release is valid from the date of signature until cancelled by the undersigned in writing. I understand that my participation in GED® Testing will be kept confidential and will not be used in any media manner other than stated above without my consent.

This release form has been read and reviewed with me, and I understand its contents
(Student Signature)

Clear
(Guardian's Signature)

Clear
(Date)

MonthDayYear
Date
Address

(Street Address/P.O. Box)

Street Address Line 2

(City)(State)

(Zip)
Should be Empty:

Arkansas Adult Education

Student Section