Outreach Classes Intake Form

1.	Date Started in Class

2.	Please choose your class*
	Please choose your class* Airport ELL Marsden ELL Goodwill Youth Build Goodwill Construction Lower Goodwill Soldering Goodwill Business Goodwill Construction Upper Other Other, please specify

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.	Can we text you at this phone number?*
	Can we text you at this phone number?* Yes No

13.	What is the best way to contact you? (Please choose one).*
	--Please Select--Phone callText messageEmail

14.	Email Address

15.	Birth Date*
	mm/dd/yyyy

16.	Gender*
	Gender* Female Male

17.	Country of Birth*

18.	Primary Language*

19.	Are You Hispanic*
	Are You Hispanic* Yes No

20.	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

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

22.	Date of unemployment or start date of job search

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

24.	Date when MFIP ended

25.	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

26.	Education Location*
	Education Location* Non US Education US Education

27.	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

28.	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

29.	Emergency Contact: Name and Phone Number

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

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

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

33.	Comments or Test Score