Student Goals Update

"*" indicates required fields

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Date

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Student ID

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How 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*

Month123456789101112

Day12345678910111213141516171819202122232425262728293031

Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Gender:*

Male

Female

Non-binary

First Language*

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Did you have an Individualized Education Plan (IEP) or 504 Plan while attending school?

Yes

No

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Name of Emergency Contact

First Last

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Emergency Contact's Phone Number

Goal 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?

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Student 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.

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Employment 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.

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Employer:

Learner Agreement

I 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

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Instructor Agreement

As 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.

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Instructor Signature

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Date

MM slash DD slash YYYY

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Additional Instructor Signature

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Date

MM slash DD slash YYYY