<p> Intake Form EFFECTIVE JULY 1, 2017 Intake Date Program Enrollment Type: _____ / ____ / ______</p><p> ABE  ASE  ELA/ESL  Family Literacy  IELCE  Correctional Facility  Other Institution</p><p>Social Security #: ______– ______– ______Birth Date: _____ / _____ / ______(month/day/year)</p><p>Name: Last First MI</p><p>Home Address: (Mailing Address / PO Box) City State Zip County</p><p>Home Phone Email</p><p>Follow-Up Survey Information  Personal Contact (select preferred method of contact)  Phone  Mail  Email</p><p>ETHNICITY AND GENDER WORK STATUS LIFE EXPERIENCES DISABILITY EDUCATION RACE 3) Check all that apply: Highest Education Level  Male 1) Choose only one:  Employed (circle one) Do you have a record of a Completed on Entry:  Cultural Barriers disability (e.g., learning  Female  Hispanic/Latino Full- time job disability, physical  Disabled  Not Hispanic/Latino disability, or other type of ______Part- time job  Displaced Homemaker disability)?  Economic Disadvantage  Yes  No  Unemployed  English Language Learner Are you a Would you like to request a Was education completed in the single 2) Check all that apply:  Not in Labor Force  Ex-Offender reasonable accommodation for U.S.? parent? any type of disability (e.g.,  American Indian or  Exiting TANF w/in 2 learning disability, physical Alaska Native Do these issues impact years disability, or other type of  Yes disability)?  Yes  No  Asian your ability to participate  Foster Care Youth in the AE program?  No  Yes  No  Black or African  Homeless American If yes, what accommodation?  Transportation  Long Term  Native Hawaiian or Unemployment other Pacific Islander  Child Care  Low Literacy Levels  White ______ Migrant Farmworker  Seasonal Farmworker Household Income:  $0 - 12,060  $12,061 – 16,240  $16,241 – 20,420  $20,421 – 24,600  $24,601 – 28,780 (Check box)  $28,781 – 32,960  $32,961 – 37,140  $37,141 – 41,320  $41,321 – 45,501.0  > $45,502</p><p>How many people are in your household? ______</p><p>How did you hear about this program? ______</p><p>Release of Information</p><p>All above information is self-reported and accurate. I understand the New Mexico Higher Education Department and the local Adult Education program may release my information for purposes of education or employment research/reporting.</p><p>______Student Signature Date </p>