Enrollment Form - Prospect Inquiry

Fields marked with the asterisk sign(*) are required fields

Personal Details

First Name *

Last Name *

Middle Initial

Date of Birth *

SSN

Gender *

Male Female

U.S. Citizen?

Marital Status

Other ID (Passport #, visa info, etc)

Suffix

How did you learn about us? *

Other source

* Required

Location of One stop/Am. Job Center/Unemployment Ofc

What would you like to do? Choose all that apply *

You have selected the following options:

Address Information

Street 1 *

Street 2

City *

State

Zip code *

Address type

Parish *

Provider

Phone Details

Primary Phone Number *

CELL LANDLINE

Phone Type *

Emergency Contact

Last Name

First Name

Phone Type

Primary Phone Number

Email *

Email Type

Ethnicity Details

Are you Hispanic / Latino?

AMERICAN INDIAN OR ALASKA NATIVE

ASIAN

BLACK OR AFRICAN-AMERICAN

WHITE

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

Program Details

Primary Program

Pathways Program

State Keyword

Secondary Program 1

ESL Student

Local Keyword (FLAGS)

Secondary Program 2

Native Language

Secondary Program 3

Secondary Program 4

Country of Highest Education and/or Country Prior to Entering Adult Ed

Past Enrollment in Adult Ed Program

Have you been enrolled in Adult Ed Program before?

Enrollment Details

Current employment status

Employer

Employment Date

Occupation

Migrant and Seasonal Farmworker Status

Long Term Unemployed (- >= 27 consecutive weeks)

Single Parent

Public Assistance

Rural Area

Displaced Homemaker

Dislocated Worker

Cultural Barriers Hindering Employment

In Foster Care

Aged out of Foster Care

Exhausting TANF Within 2 Years (Part A Title IV of the Social Security Act)

Individual with a Disability

Job Corps

Youth Build

Low Levels of Literacy

Low Income

Tick the checkbox if any of the following conditions are true:

(A) Receives, or in the 6 months prior to application to the program has received, or is a member of a family that is receiving or in the past 6 months prior to application to the program has received:

(i) SNAP or Louisiana Purchase Card Assistance through the supplemental nutrition assistance program under the Food and Nutrition Act of 2008 (7 USC 2011 et seq)

(ii) TANF Assistance through the temporary assistance for needy families program under part A of Title IV of the Social Security Act (42 USC 601 et seq)

(iii) SSI Assistance through the supplemental security income program under Title XVI of the Social Security Act (42 USC 1381); or

(iv) State or local income-based public assistance
(Louisiana Medicaid, Section 8 Housing, Kinship Care, Child Care Assisstance,
LSU Hospital Free Care, Free Dental Program)

(B) Is in a family with total family income that does not exceed the higher of the poverty line or 70% of the lower living standard income level

(C) Is a youth who receives, or is eligible to receive a free or reduced price lunch under the Richard B Russell National School Lunch Act (42 USC 1751 et seq);

(D) Is a foster child on behalf of whom State or local government payments are made

(E) Is an individual with a disability whose own income is the poverty line but who is a member of a family whose income does not meet this requirement;(e) Is an individual with a disability whose own income is the poverty line but who is a member of a family whose income does not meet this requirement;

(F) Is a homeless individual or a homeless child or youth or runaway youth (see No 700 of this chart); or

(G) Is a youth living in a high-poverty area

Ex-Offender: Tick the check boxes if any of the following conditions are true:

Are you a person who either
(A) has been subject to any stage of the criminal justice process for committing a status offense or delinquent act, or

(B) requires assistance in overcoming artificial barriers to employment resulting from a record of arrest or conviction for committing delinquent acts, such as crimes against persons, crimes against property, status offenses, or other crimes

Homeless Individual, Homeless Children and Youths, or Runaway Youth:

Check if:
(A) Lacks a fixed, regular, and adequate nighttime residence; this includes an individual who:

(i) is sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason

(ii) is living in a motel, hotel, trailer park, or campground due to a lack of alternative adequate accommodations

(iii) is living in an emergency or transitional shelter

(iv) is abandoned in a hospital; or

(v) is awaiting foster care placement

(B) Has a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, such as a car, park, abandoned building, bus or train station, airport, or camping ground;

(C) Is a migratory child who in the preceding 36 months was required to move from one school district to another due to changes in the parent’s or parent’s spouse’s seasonal employment in agriculture, dairy, or fishing work; or

(D) Is under 18 years of age and absents himself or herself from home or place of legal residence without the permission of his or her family (i.e., runaway youth)

Adult: Have you received services employment or training services through the One-Stop?

Are you a person who either
(A) has been subject to any stage of the criminal justice process for committing a status offense or delinquent act, or

Date of last Service

Provider's Name

Type of Service

Youth: Have you received services employment or training services through the One-Stop?

Are you a person who either
(A) has been subject to any stage of the criminal justice process for committing a status offense or delinquent act, or

Date of last Service

Provider's Name

Type of Service

Vocational Rehabilitation:
Have you received Vocational and Rehabilitation services ?

Wagner-Peyser Act:
Have you received technical training assistance from the one-stop?

School Status at Participation:

Record (1) if the participant has not received a high school diploma or its recognized equivalent and is attending any secondary school (including elementary, intermediate, junior high school, whether full or part-time), or is between school terms and intends to return to school

Record (2) if the participant has not received a high school diploma or its recognized equivalent and is attending an alternative high school or an alternative course of study approved by the local educational agency whether full or part-time, or is between school terms and is enrolled to return to school

Record (3) if the participant has received a high school diploma or its recognized equivalent and is attending a post-secondary school or program (whether full or part-time), or is between school terms and is enrolled to return to school

Record (4) if the participant is not within the age of compulsory school attendance; and is no longer attending any school and has not received a high school diploma or its recognized equivalent

Record (5) if the participant is not attending any school and has either graduated from high school or has attained a high school equivalency

Record (6) if the participant is within the age of compulsory school attendance, but has not attended school for at least the most recent complete school year calendar quarter and has not received a high school diploma or its recognized equivalent

Received Training

Eligible Training Provider - Name

Type of Training Service #1

Eligible Training Provider - Program of Study

Eligible Training Provider - CIP Code

Type of Training Service #2

Type of Training Service #3

Disability Details

ADHD

AUTISM

DEAF-BLINDNESS

DEAFNESS

EMOTIONAL DISTURBANCE

HAD AN IEP IN K-12

HARD OF HEARING

INTELLECTUAL DISABILITY

MULTIPLE DISABILITIES

ORTHOPEDIC IMPAIRMENT

OTHER HEALTH IMPAIRMENT

SPECIFIC LEARNING DISABILITY

SPEECH OR LANGUAGE IMPAIRMENT

TRAUMATIC BRAIN INJURY

VISUAL IMPAIRMENT

Educational Details

Highest degree or level completed *

Location *

Highest School Grade Completed At Program Entry

Goal