Basic Education Classes and GED Preparation

Date

Social Security Number

Class Site

Telephone Number

Name *

First

Middle

Last

Date of Birth

Age

Address

Address Line 1

Address Line 2

City

State

Zip Code

Gender

Marital Status

Employer

Supervisor

Employer Phone Number

Job Title

Schedule

Days and Hours

Are there any health problems that could affect your performance or attendance?

Emergency Contact

Emergency Contact Phone Number

Highest Grade Completed

Last School Attended

If the highest grade completed is 12th grade, which of the following apply to you? (select all that apply)

High School Diploma
GED Certificate
Certificate of Completion

Did you attend special education classes?

Why did you drop out of school?

Have you attended Adult Education class before?

If "Yes," where and when?

Do you need Childcare Services to attend class?

If "Yes," list age(s) of child(ren)

Do you need transportation to attend class?

If "Yes," check all that apply

Day
Night
Both

If "Yes," give directions to your house.

Are you a registered voter?

If "Yes," check all that apply

County
Tribal

Do you have a driver's license?

If "No," are you interested in getting one?

Check the one that applies if you had a license and no longer have one:

Expired
Revoked

What year?

Student Signature

Clear Signature

CDIB

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