WABERS Student Information Intake Form
SID: Quarter:
Name: Instructor:
(first) (last)
1. Entry Status (Check all that apply) 2. Employment Status (Check one)
£ Disabled (any disability, including LD) £ Employed (currently working)
£ Learning disabled (also check Disabled box above) £ Unemployed (currently looking for work)
£ On public assistance (food stamps, Gov. help, etc.) £ Not in the labor force (NOT working, not looking for work)
3. Type of Schooling (must check one) £ U.S. based schooling £ Non-U.S. based schooling
4. Highest Degree or Level of School Completed (Check one)
£ No schooling £ Grades 9-12 (high school, no diploma) £ Some college, no degree
(not including ESL classes)
£ Grades 1-5 (elementary) £ High School Diploma or alternate £ College or professional
(certificate or degree)
£ Grades 6-8 (middle) £ GED £ Unknown
Special Programs (For staff use only)
£ Distance Learning £ I-BEST £ On-Ramp to I-BEST
£ English Literacy/Civics £ I-BEST at Work £ Skill Link
£ Family Literacy Program £ I-DEA £ Volunteer Literacy Program
£ High School Completion £ LDSI £ Workplace Literacy Program
£ HS 21+
Student SSN Disclaimer
The Washington State Board for Community and Technical Colleges (SBCTC) pursuant to RCW 28B.50.090 authorizes this organization to ask you to provide your social security number. The number will be used for keeping records, research on students in general, and summary reporting. Your number also will be provided to the SBCTC. The SBCTC gathers information about students and programs to meet state and federal reporting requirements. It also helps to plan, research and develop programs. This information, which includes employment and wage information held by the Employment Security Department, helps to support the progress of students and their success in the workplace and other educational programs. When conducting research, your social security number will only be disclosed in a manner that does not permit personal identification. Your social security number will never be used to report personal information. By providing your social security number, you are consenting to these uses as identified. Provision of your social security number and consent to its use is not required and if you choose not to do so, you will not be denied any right, benefit, or privilege provided by law. You may revoke your consent for the use of your social security number at any time.
Consent Yes £ No £
Student Signature Date
5. Goals (Check all that apply)
A. Why are you taking GED preparation courses?
¨ I want to get a job
¨ I want to get a better job
¨ I want to do better at my current job
¨ I want to get a GED
¨ I want to get into a certificate (job training) program
¨ I want to get a degree from a 2- or 4-year college
¨ I want to take college classes that I enjoy
¨ I need education for my life in general
¨ Other: ______
B. Which classes do you plan to take at NSCC next quarter?
¨ More ABE/GED classes
¨ Job training classes (including I-BEST Nursing, Accounting, etc.) in a certificate program.
¨ Regular college classes
¨ None
¨ Other: ______
Please read the statement on the front of the form. By checking the yes box, you allow the State of Washington to use your Social Security Number (SSN). For example, the State of Washington uses SSNs to determine how many students in the State of Washington have gotten a job each year. The State of Washington has to report this information to the federal government. Using SSNs is the only effective way to do this. Your social security number will never be used to report personal information. You are not required to give your Social Security Number. Whether or not you provide your SSN, you can still enroll in our program.
Spanish
Por favor lea la declaraciόn de abajo. Con su firma usted autoriza al estado de Washington de usar su número de seguro social(SSN). Por ejemplo, el estado de Washington usa números de seguro social para determinar cuantos estudiantes en el estado de Washington han obtenido un empleo cada año. El estado de Washington tiene que reportar esta información al gobierno federal. Usando los números de seguro social es la única forma efectiva de hacer esto. Tu número de seguro social nunca sera usado para reportar información personal. Tu no estas obligado a proporcionar tu número de seguro social. Si tu das o no tu número de seguro social no impedira tu inscripción en nuestro programa.
Mandarin