LACES Student Intake Form 2024-2025 Academic Year Program You are Completing(Required) ESL – English as a Second Language ABE – Adult Basic Education (includes HS+and GED) I-BEST – Integrated Basic Education and Skills Training Name(Required) First Last Bellevue College ctcLink ID(Required) Social Security Number Quarter:(Required)Which quarter are you beginning classes?Summer 2024Fall 2024HiddenOrg Highest Level of Schooling Completed:(Required) No Schooling Grades 1-5 Grades 6-8 Grades 9-12 (no diploma) High School Diploma or alternate High School Equivalent (e.g., GED®) Some college or technical, no degree College or professional degree Unknown Where did you complete your highest level of school?(Required) In the U.S. Not in the U.S. Current Employment Status:(Required) Employed Not looking for work currently Temporarily not working, but returning to the same employer Not employed, but looking for work Retired not working Received termination notice or separating from military WIOA Employment Considerations– None of your responses or lack of responses will affect your ability to participate in our programs.Check any that apply. Bias Considerations – a person who perceives themself as possessing attitudes, beliefs, customs, or practices that influence a way of thinking, acting, or working that may serve as a hindrance to employment. Individual with disability— a person with a physical or mental impairment that substantially limits one or more of the person’s major life activities. Displaced homemaker— a person who previously provided unpaid services to the family (for example: a stay-at-home parent), is no longer supported by the spouse, or is the dependent spouse of a member of the Armed Forces, is unemployed or underemployed, and is having trouble finding or upgrading employment. Low-income individual — a person who within 6 months has received income-based assistance, such as housing supplement or food stamps, or whose total family income is below 70 percent of the lower living standard income level. English Language Learner – a person with limited ability in speaking, reading, writing, or understanding the English language. – Justice Involved — a person who has been subject to any stage of the criminal justice process. Exhausting TANF— a person within 2 years of using up lifetime eligibility. Foster care youth— a person who is currently in foster care or has aged out of the foster care system. Homeless individual — a person without a fixed, regular and adequate nighttime residence or runaway youth. Long-term unemployed — a person who has been unemployed for 27 or more consecutive weeks. Skills Development — a person wanting to improve their ability to compute and solve problems, or read, write, or speak English at a level necessary to function on a job, in their family, or in society. Single parent — a person who is single, separated, divorced or a widowed and has primary responsibility for one or more dependent children under age 18 or is currently pregnant. Migrant FarmworkerCheck only if this applies. A seasonal farmworker and whose agricultural labor requires travel to a job site such that the farmworker is unable to return to a permanent place of residence within the same day. Seasonal FarmworkerCheck only if this applies. A low-income individual who for the past 12 consecutive months has been primarily employed in agriculture or fish farming labor that is characterized by chronic or seasonal unemployment or underemployment and faces barriers to economic self-sufficiency. We are required to ask you for your Social Security Number (SSN). If you do not have one or do not submit one, you will still be able to enroll in this program. In keeping with state and federal law, this organization will protect your SSN from unauthorized use and disclosure. Your personally identifiable information will be used to verify assessment and academic records within our provider network, and for SBCTC to conduct educational and employment outcomes research.(Required) I agreeI certify that the information provided on this form is correct and true to the best of my knowledge.(Required)Student Electronic Signature Date MM slash DD slash YYYY Last Updated June 6, 2024
