WorkReady U Intake Form
Date
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Month
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Day
Year
Date
Type of Student
Please Select
16 or 17 year old Minor-HiSET
18 year Old Adult-pursuing HiSET
19 or older Adult-pursuing HiSET
18 or older Adult-pursuing English Classes
Class Location
Please Select
Abbeville
Crowley
Franklin
Lafayette
Morgan City
New Iberia
Opelousas
St. Martinville
Ville Platte
Class
Please Select
Abbeville AM-Adults ONLY
Abbeville PM-Minors ONLY
Crowley AM-Adults ONLY
Crowley PM-Minors ONLY
Franklin AM-Adults ONLY
Franklin PM-Minors ONLY
Lafayette AM-Adults ONLY
Lafayette Day-English Learners
Lafayette AM-Minors ONLY
Lafayette PM-Adults ONLY
Lafayette PM-Minors ONLY
Lafayette Nights-Adults ONLY
Lafayette Nights-English Learners
Morgan City AM-Adults ONLY
Morgan City PM-Minors ONLY
Morgan City Night-English Learners
New Iberia AM-Adults ONLY
New Iberia PM-Minors ONLY
New Iberia Nights-Adults ONLY
New Iberia Nights-English Learners
Opelousas AM-Adults ONLY
Opelousas PM-Minors ONLY
St. Martinville AM-Adults ONLY
St. Martinville PM-Minors ONLY
Ville Platte AM-Adults ONLY
Ville Platte PM-Minors ONLY
AEONLINE
Name
*
First Name
Middle Name
Last Name
Suffix
Preferred Pronouns
Please Select
He/Him
She/Her
They/Them
Pronouns not listed
Home/Mailing Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Cell Phone Number
*
Alternate number
Student Email Address
*
Parent Email Address (only for 16-17 minors)
example@example.com
Emergency Contact Information
*
First Name
Last Name
Relationship
*
Phone number
*
Social Security Number
ITIN
Are you a U.S. Citizen?
*
Please Select
Yes
No
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Gender
Please Select
Male
Female
Martial Status
Please Select
Single
Married
Divorced
Widowed
Other
Language Spoken at Home
Country of Birth if not US
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Hispanic, Latina, or Latino?
*
Please Select
Yes
No
Are you a parent?
Please Select
No
parent of children 1-5
parent of children 6-10
parent of children 11-13
parent of children 14-18
Are you a veteran?
Please Select
Yes
No
Highest Degree or Level Completed
*
Please Select
No Formal School
Completed 1 Year
Completed 2 Years
Completed 3 Years
Completed 4 Years
Completed 5 Years
Completed 6 Years
Completed 7 Years
Completed 8 Years
Completed 9 Years
Completed 10 Years
Completed 11 Years
Completed 12 Years (HSE Diploma Not Earned) Completed 13 Years
Completed 14 Years/ Associates Degree/Technical Diploma
Completed 15 Years
Completed Bachelors Degree
Completed Beyond Bachelors Degree
High School Equivalency
Certificate of Attendance or Completion (HS only) Post Secondary Degree/Certificate Earned Completed 12 Years (HS Diploma Earned)
Last High School Attended for minors only
Highest School Grade Completed at Program Entry:
*
Please Select
No Formal School
Completed 1 Year
Completed 2 Years
Completed 3 Years
Completed 4 Years
Completed 5 Years
Completed 6 Years
Completed 7 Years
Completed 8 Years
Completed 9 Years
Completed 10 Years
Completed 11 Years
Completed 12 Years
Where was your highest level of school completed?
Please Select
Non US-Based
US Based School
Have you ever been enrolled in Adult Education before?
Please Select
Yes
No
Accessibility Details-Select all that apply
Please Select
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
DYSCALCULIA
DYSGRAPHIA
DYSLEXIA
RELATED TO NEUROLOGICAL IMPAIRMENTS
What is your current work status? (Select all that apply)
*
Please Select
Employed
Unemployed
Not in the labor force or not available for work
Employed, but received notice of termination or military separation pending
Not working, but looking for work
Retired
Employment Details
*
Please Select
Full-time
Part-time
Not in the labor
If you are currently employed, what industry cluster do you work in?
If you could get a job or change jobs, what industry cluster would you like to work in?
Employer
*
Occupation
*
Have you (or someone in your household) received any of the following in the last six months?
Please Select
TANF (Temporary Assistance for Needy Families)
SNAP (Supplemental Nutrition Assistance Program)
SSI (Supplemental Security Income)
State or local income-based public assistance
Do any of the following statements apply to you?
Please Select
I live in low income housing
Divide the total annual household income by the number of family members, including yourself, who have lived in your household in the last 6 months. If the average yearly income is $12,750 or less, check this box.
I am a former homemaker who is having trouble finding a job or a better job.
I am a single parent. I am unmarried or separated from my spouse and have primary responsibility for one or more dependent children under the age of 18, or I am a single, pregnant
am homeless. I live in a motel, hotel, campground, transitional housing, or with another person because I lost my house or apartment.
I have a criminal record that makes it hard to find a job.
Iam in the foster care system (or used to be) and I am less than 24 years old.
am a farmworker.
I am a seasonal farmworker who has worked in the last 12 months in agriculture or fish farming labor.
I am a seasonal farmworker with no permanent residence (migrant I am a dependent of a farmworker.
None of these apply.
What is your primary goal? (choose one)
*
Please Select
I want to earn a high school equivalency diploma (HiSET, formerly GED)
I want to learn English
I want to work on my computer skills, financial skills, or health literacy
I want to participate in workforce trainings while working on my reading, writing, and math skills
I want to explore career options
I want to work on my reading, writing, or math skills
I want to prepare for college
I want to start college classes while working on my reading, writing, and math skills
I want to start college classes while earning my high school equivalency diploma (HiSET, formerly GED)
What other goals would you like to pursue? (optional, choose all that apply)
Please Select
I want to earn a high school equivalency diploma (HiSET, formerly GED)
I want to learn English
I want to work on my computer skills, financial skills, or health literacy
I want to participate in workforce trainings while working on my reading, writing, and math skills
I want to explore career options
I want to work on my reading, writing, or math skills
I want to prepare for college
I want to start college classes while working on my reading, writing, and math skills
I want to start college classes while earning my high school equivalency diploma (HiSET, formerly GED)
Do any of the following goals apply to you?
Please Select
Improve basic literacy skills
Obtain citizenship skills
Other personal goals
Improve English language skills
Achieve work-based project learner goals
I want to increase my involvement in my children's education by:
Please Select
Helping more frequently with their schoolwork Increasing contact with my children's teachers to discuss children's education.
Being more involved in my children's school, such as attending school activities and parent meetings or volunteering.
I want to increase my involvement in my children's literacy-related activities by:
Please Select
Reading to children.
Visiting a library.
Purchasing books or magazines.
Learning Preferences What types of classes are you interested in? (check all that apply)
Please Select
On Campus - in-person courses where students meet during a specific time as a group
Online, Self-Paced - online coursework completed when a learner is ready
Online, Cohort - online course where students meet at a specific time as a group
Hybrid - some online and some in-person
What times are best for you to attend classes? (check all that apply)
Please Select
Morning
Afternoon
Night
Weekend
Do you have access to a computer or device to participate in online classes or resources?
Please Select
Yes
No
Do you have access to the internet at home?
Please Select
Yes
No
How did you hear about us?
*
Please Select
TV
Radio
Social Media
Brochure
Career Compass
Coach
Recruiter
Faculty/Staff
Family Member
Former Student
Friend
High School Counselor
Internet Search
Newspaper
One Stop-American Job Center
Unemployment Office
Social Service Agency
Other
Individual with a Disability Notice (optional disclosure) In the Americans with Disabilities Act of 1990, a disability is defined as a physical or mental impairment that substantially limits one or more of a person's major life activities. Are you an individual with a disability?
*
Please Select
Yes
No
Do not wish to disclose
Accommodations Agreement If you have a disability and/or a condition for which you would like special accommodations for instruction or testing, it is your responsibility to notify the program's administrative office and provide professional documentation.
*
Check here to indicate that you understand your responsibility to request accommodations.
Signature
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Printed Name
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Date
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