Site: ______ABLE Staff:______ / STUDENT REGISTRATION
FORM
SFY 2001 (2000 - 2001) / Date Form is completed:______
Social Security #: ______- ______-______
Name: ______
Last First M.I. Maiden (or Other Former Name)
Address: ______Apt.#:______Telephone: Home: (______) ______-______
City: ______State: ______Zip:______County: ______Work: (______) ______-______
Age:______Date of Birth:______Place of Birth:______
Month Day Year City State Country
Emergency information: Contact Person: ______Phone: ______Allergies or conditions we should know about: ______
Fill in the correct circle for each question.
1. m Male m Female
2. Ethnic Background: MARK ONLY ONE.
m American Indian or Alaska Native
m Asian
m Black or African American
m Hispanic or Latino
m Native Hawaiian or Other Pacific Islander
m White
3. Are you a US Citizen? m Yes m No
4. Are you a US Veteran? m Yes m No
5. Are you registered to vote? m Yes m No
6. Education:
Last full grade completed:______
MARK ALL THAT APPLY.
m High school/GED graduate or equivalent in country of origin
m Attended college/university/trade school
m Graduated from college/university/trade school
m Other (Specify: ______)
m Name and location of last school attended:
______
7. Number of children under 18 living in your home:______
8. Are you a single parent? m Yes m No
9. Do you receive public assistance?
m Yes m No
If yes, mark all types that apply:
m TANF
m Food Stamps only
m Subsidized Housing
m Medicaid #: ______
m Other (Specify: ______)
10. Employment Status: MARK ONLY ONE.
m Employed, Full time
m Employed, Part time
m Not employed, but looking for a job
m Not employed, not looking for a job
m Retired
11. How did you find out about this program? MARK ALL THAT APPLY.
m Employer
m Family member
m Friend
m I attended before
m Newspaper ad
m GED on TV Estimated ______hours viewed
m Television/Radio ad
m Brochure/Flyer
m Department of Job and Family Services
m Other (Specify: ______)
12. What is your primary goal for coming to this program? MARK ONLY ONE.
m To improve basic skills
m To improve English language skills (ESOL)
m To obtain a job
m To retain current job
m To earn GED or secondary school diploma
m To enter postsecondary education or training
m To improve basic skills to increase involvement in children's education (relates to school activities)
m To improve basic skills to increase involvement in children's literacy-related activities
13. (Optional) What is your secondary goal for coming
to this program? MARK ONLY ONE.
m To improve basic skills
m To improve English language skills (ESOL)
m To obtain a job
m To retain current job
m To earn GED or secondary school diploma
m To enter postsecondary education or training
m To increase involvement in children's education (relates to school activities)
m To increase involvement in children's literacy- related activities
m To decrease public assistance received
m To obtain citizenship skills
m To register to vote or to vote for the first time
m Other (Specify:______)
Name:______
SS#: _____-_____-______
Optional Questions
A. General
14. Did you pass the Ohio 9th grade proficiency test?
m Yes, all of the sections
m Some of the sections. Specify ______
m No ______
m N/A ______
15. Do you have:
a driver’s license? m Yes m No
a library card? m Yes m No
reliable transportation? m Yes m No
reliable child care? m Yes m No m N/A
B. Workplace
16. Employer:
______
17. Dept/area: ______Shift:______
18. In what field is your current job?
m Business
m Education
m Farming
m Manufacturing/trade
m Retail/sales
m Service
m Other (Specify: ______)
19. Present skills/experience:
m Clerical (data entry, cash register, secretarial, etc.)
m Computer
m Manual (bricklayer, carpenter, heavy equipment operator, etc.)
m Retail (cashier, stocker, sales clerk, etc.)
m Service (health care, child care, etc.)
m Technical (TV, refrigerator, auto, etc.)
m Other (Specify: ______)
C. ESOL
20. Date when you entered the country:
______
21. Do you plan to stay in the US permanently?
m Yes m No How long?______
22. What is your native language?
23. What languages do you speak?
24. Have you studied English before?
m Yes How long?______m No
25. I am here to improve my
m speaking
m writing
m reading
m listening
m knowledge of American culture
26. I am here to prepare for The U.S.
Citizenship Test. m Yes m No
STAFF USE ONLY FOR INITIAL PLACEMENT RESULTS
MARK ALL THAT APPLY. **
Student Status
m Disabled m Rural* Resident
m Displaced Homemaker m Dislocated Worker
m Migrant Farm Worker m Homeless
Program Type
m Workplace Literacy m Family Literacy
m Institutionalized Settings m Corrections Facility
m Jail m Community Corrections
m Homeless Program
*defined by NRS as places of less than 2,500 inhabitants and outside urbanized areas
ENTRY LEVEL
Mark the ABE level:
m Beginning ABE Literacy m Beginning Basic Education m Low-Intermediate
(0 - 1.9) (2.0 - 3.9) (4.0 - 5.9)
m High-Intermediate m Low Adult Secondary m High Adult Secondary
(6.0 - 8.9) (9.0 - 10.9) (11.0 - 12.9)
Mark the ESOL level:
m Beginning ESOL Literacy m Beginning ESOL m Low-Intermediate
m High-Intermediate m Low Advanced m High Advanced
**Note: Refer to definitions in the O-PAS manual for clarification of categories.