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

Male          Female
Address Information
Phone Details
CELL                   LANDLINE
Emergency Contact
Email
Ethnicity Details
 AMERICAN INDIAN OR ALASKA NATIVE

 ASIAN

 BLACK OR AFRICAN-AMERICAN

  WHITE

  NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

Program Details
ESL Student


Past Enrollment in Adult Ed Program
   Have you been enrolled in Adult Ed Program before?
Enrollment Details
    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)
    Low Levels of Literacy
    Low Income
(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
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
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)
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
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

Have you received Vocational and Rehabilitation services ?

Have you received technical training assistance from the one-stop?
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

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

Goal