Outreach Classes Intake Form
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Outreach Intake Form
This form is for Hubbs Outreach classes only. Please fill out as completely as possible.
1.
Date Started in Class
2.
Please choose your class
*
Please choose your class
*
Airport ELL
Marsden ELL
Goodwill Youth Build
Goodwill Career Prep
Goodwill Business
Goodwill Construction
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 call
Text message
Email
14.
Email Address
15.
Birth Date
*
mm/dd/yyyy
16.
Gender
*
Gender
*
Female
Male
Non-Binary
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