SPC Classes Intake Form

1.	Date Started in Class

2.	Please choose your class.*
	Please choose your class.* SPC Math M/W 10-12 Thao SPC Math M/W 12-2 Thao SPC Math T/R 10-12 Thao SPC Math T/R 12-2 Thao SPC Math T/R 4-6 Thao SPC Math Sat 8-12 Dang SPC Math T/R 6-8 Dang SPC Math F 8-12 Dang College Readiness Tier 2 SPC SPC Math Summer MTW 10:00 Dang SPC Math Summer TWTh 12:00 Dang SPC Math Summer TWR 2:00 Dang SPC Math Summer MTW 5:00 Dang

3.	Social Security Number

4.	Last Name*

5.	First Name*

6.	Middle Name

7.	Street Address (Include Apt #)*

8.	City, State, and Zip Code*
	City   State   Zip Code Address

9.	COUNTY of Residence

10.	School District of Residence

11.	Phone Number*

12.	Email Address

13.	Birth Date*
	mm/dd/yyyy

14.	Gender*
	Gender* Female Male

15.	Country of Birth*

16.	Primary Language*

17.	Are You Hispanic*
	Are You Hispanic* Yes No

18.	Race* Select at least 1.
	American Indian or Alaskan Native    Asian    Black or African American    Native Hawaiian or Other Pacific Islander    Two or More Races    White

19.	Work Status*
	Work Status* Employed Unemployed (Looking for work) Not in Labor Force

20.	Date of unemployment or start date of job search

21.	Public Assistance
	MFIP    No Public Assistance    Other Public Assistance    SNAP    Other, please specify

22.	Date when MFIP ended

23.	Highest Formal Education Level *
	Highest Formal Education Level * No Schooling Grades 1-5 Grades 6-8 Grades 9-12 (No Diploma) Secondary School Diploma or Alternate Credential (HD) Secondary School Equivalent (GED) Some Postsecondary Education, No Degree Postsecondary or Professional Degree Unknown

24.	Education Location*
	Education Location* Non US Education US Education

25.	NRS Data (Check all that apply)
	Disability    Learning Disability    Dislocated Worker    Displaced Homemaker    Probation/Paroll    Homeless    Low Income    Migrant Worker    Single Parent with children under 18

26.	Data Privacy Statement: Sometimes job counselors, social workers, public housing, daycare agencies, employers, or other schools request information such as attendance, schedules, and test scores for this school. Do we have your permission to release this information?*
	Data Privacy Statement: Sometimes job counselors, social workers, public housing, daycare agencies, employers, or other schools request information such as attendance, schedules, and test scores for this school. Do we have your permission to release this information?* Yes No

27.	Emergency Contact: Name and Phone Number

28.	MFIP Counselor or Probation Officer
	Name   Agency   Phone Number   Fax Number   Email Counselor/Probation

29.	Referral Source: How did you hear about this class or program?

30.	Children enrolled in St. Paul Public Schools? If Yes how many?

31.	Comments or Test Score