SPC Classes Intake Form
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SPC Intake Form
This form is for St. Paul College classes only. Please fill out as completely as possible.
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 6-8 Thao
SPC Math T/R 12-2 Thao
SPC Math MWTH 4-6 Thao
SPC Math Sat 8-12 Dang
SPC Math T/R 10-12 Dang
SPC Math M/W 12-2 Dang
SPC math T/H 4-6 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