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Adult Education & Literacy Student Intake Form
Students who need to prepare for the GED test or take basic education or English as a Second Language (ESL) courses. An information form may be completed prior to orientation or at orientation. For additional information, please call 217.875.7211, ext. 6355 or email us at firstname.lastname@example.org
Legal First Name
Legal Middle Name
Legal Last Name
Birth Date (mm/dd/yyyy)
Are you Hispanic or Latino/Latina?
Race (Choose one or more)
English is a second language?
Please record native language
Do you receive Public Assistance?
Public Assistance Number
Which type of area do you live?
How did you hear about the program?
Barriers to Employment (check all that apply)
Do you reside outside of the United States?
Address, continued (as needed)
County of residence
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Primary Phone Number
Texting Phone Number
This number may be used to text important messages regarding to your education. Charges may be incurred by your carrier for receiving text messages.
Confirm Email Address
Emergency Contact Name
Emergency Contact Phone Number
Planned Starting Month
Planned year to start program
Select one of the 16 Career Clusters identified below as the career pathway you intend to follow
Type of Student (hidden)
Reason attending (hidden)
Intended Area of Emphasis
Month/Year Last Enrolled in a School
Number of School Years Completed
US High School Equivalency Upon Entry?
US Diploma Upon Entry?
Current Employment Status
What is your occupation?
Richland Community College does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs. The following person(s) has been designated to handle inquiries regarding the nondiscrimination policies:
Gabriela Brunner, Title IX Coordinator at phone 217-875-7211 EX 6280 Leanne Brooks, 504 Coordinator, at phone 217-875-7211 EX 6362
For further information on notice of nondiscrimination, visit http://wdcrobcolp01.ed.gov/CFAPPS/OCR/contactus.cfm for the address and phone number of the office that serves your area, or call 1-800-421-3481.
I certify that all of the information on my Intake Form is correct and complete.