Rend Lake College Skills Center Student Intake Form First Name Last Name Middle Initial Preferred Name / Nickname Date of Birth mm/dd/yyyy Street Address City State Zip Code Please select a value... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Email Address County of Residence Primary Phone Number Alternative Phone Number Emergency Contact Name & Phone Number Gender Marital Status Are you Hispanic or Latino? Please select a value... Male Female Other Please select a value... Single Married Divorced Widowed Other Yes Are you from one of the folloing racial groups?  Select all that apply Please identify your primary racial/ethnic group Please select a value... American Indian or Alaska Native Asian Black / African American Native Hawaiian or Other Pacific Island White American Indian or Alaska Native Asian Black / African American Native Hawaiian or Other Pacific Island White Is English your SECOND language? Yes School Type Month & Year last enrolled in school Please select a value... U.S. Based Schooling NON-U.S. Based Schooling U.S. Highschool Equivalency upon entry? Number of school years completed​ Yes Please select a value... No Schooling Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 HS Diploma or Alternative Credential GED or other HS Equivalency Certificate Some College, no degree College or Professional Degree Unknown Disability status U.S. Diploma upon entry? Yes Please select a value... Not Disabled Documented Disability as defined by ADA Choose not to disclose Which best describes the population you live in? How did you hear about the program? Please select a value... Rural Area (less than 2,500) Urban Area w/ High unemployment (Above 50,000) Neither Please select a value... Friend or Family Member Employer One-Stop / Unemployment or DHS Office Comprehensive Connections Other Which best describes your employment status? Do you receive public assistance? Please select a value... Not in labor force (not currently seeking work) Employed Unemployed (seeking work) Employed but received notice of termination or military discharge Yes If employed, what is your occupation & number of hours per week? Barriers to employment. Check all that apply Displaced HomemakerIndividual with a disability Homeless or runawaySingle homemaker Youth in foster care / aged out of the systemLong-term unemployed Migrant & seasonal Farm WorkerExhausted TANF within 2 years English language learner, low literacy cultural barriersEx-Offender Low income Please check any that apply: In a correctional facility In a community correctional program In other institutional setting Please choose a program: If GED Prep, please select location Please select a value... GED Prep ICAPS Bridge Please select a value... Mt. Vernon - AM Mt. Vernon - PM Ina - AM YouthBuild By placing a check in the check-box​ below, you acknowledge that Rend Lake College SkillsCenter can collect this personal information for enrollment. I Agree