Student Goals Update "*" indicates required fields HiddenDate MM slash DD slash YYYY HiddenStudent IDHiddenHow do you prefer to be contacted?Select all that apply. Text Phone Call Email No Preference Name* First Middle Last Phone*Email* Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender:* Male Female Non-binary First Language* HiddenDid you have an Individualized Education Plan (IEP) or 504 Plan while attending school? Yes No HiddenName of Emergency Contact First Last HiddenEmergency Contact's Phone NumberGoal Areas - I would like to:*Check all that apply. improve basic skills. enter employment. retain employment. obtain a High School Equivalency (HSE) diploma. attend postsecondary education or job training. leave or reduce public assistance. vote or register to vote. achieve citizenship skills. increase involvement in children's education. Is there anything else that you would like the teacher to know about you?HiddenStudent Barriers I am in need of food assistance. I need help with transportation. I need help with child care. I need help with medical care. I would like help with employment or career training. I need immigration information. I need information about expungement of a criminal record. I need my foreign academic records evaluated. I need a letter from school stating that I am a student. I do not have any of these barriers at this time. HiddenEmployment Status: I am EMPLOYED. I am able to work but am currently NOT EMPLOYED. I am NOT IN THE LABOR FORCE, as I am not working, not able to work, or not looking for a job. I have been UNEMPLOYED FOR MORE THAN 26 WEEKS. I am EMPLOYED, BUT MY JOB IS BEING TERMINATED. HiddenEmployer: Learner AgreementI agree that the above goal areas are those I choose to work on at this time. I understand that for successful completion of these goals I will need to attend class 6 hours per week, complete my assignments, ask for help when I need it, and make a genuine effort to learn. If changes need to be made in my learning plan, my instructor and I will make a new agreement.Electronic Signature*Please type your full name. Your electronic signature serves as your agreement to the above Learner Agreement. Date* MM slash DD slash YYYY HiddenInstructor AgreementAs the instructor, I will do everything possible to help the learner achieve the above goals by providing appropriate instruction and by reviewing the learner's progress at regular intervals. I understand that if changes need to be made in the learning plan, the learner and I will make a new agreement.HiddenInstructor Signature HiddenDate MM slash DD slash YYYY HiddenAdditional Instructor Signature HiddenDate MM slash DD slash YYYY