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KYAE Intake and Enrollment Form

Local providers and fiscal agents should be well-versed in and adhere to FERPA and its data sharing policies. Providers are responsible for any liabilities associated
with their failure to follow those guidelines and any applicable guidance outlined in the “Implementation Guidelines” and “KYAE Contracts”.

STUDENT INTAKE INFORMATION

1 *STUDENT INFORMATION (IMPORTANT: Only provide SSN, Driver’s License, and KAERS ID in the presence of KYAE Staff.)

SSN: Driver’s License #: KAERS ID:

Middle
Last Name: First Name: Initial:

Cell Phone: Date of Birth: Email:

Preferred Method of Contact: _____text ______call _____email ______________other (please write alternate way of contact)

2 *ADDRESS
County of Residence:
Street: City:
State: Zip Code:

3 *OTHER

Do you have your GED? ÿ Yes ÿ No Do you have a high school diploma? ÿ Yes ÿ No

Last Grade Completed: How
did you hear about our services? ÿ Adult
Education Rep. ÿ Ky Career Center
ÿ Billboards ÿ Library
ÿ Career Fair ÿ Print (flyer)
ÿ Direct Mail ÿRadio
Check if completed outside U.S.: ÿ Years out of school? Gender: ÿ Male ÿ Female
I give KYAE (OAE) permission to release my contact information to
ÿ Yes
The Career Index for the purpose of providing me with one-stop
ÿ No
delivery system services include but not limited to, education and
career services.

ÿ Employer ÿSignage or Road Sign I give the Kentucky Education and Labor Cabinet [Office of Adult
ÿ Friend or Family ÿ Social Media ÿ Yes Education (OAE)] permission to release my secondary enrollment,
ÿ GED Account or Website ÿTV ÿ No GED Testing Service® information, and employment status to KYAE
ÿ Internet Search ÿ Other______________ providers as well as this enrollment information to the KY Center for
Statistics, KY Council on Postsecondary Education, the Kentucky
I give the program, in which I am enrolled, to use photographs and/or my Community and Technical College System or any other public
ÿ Yes postsecondary institution.
name for reporting and achievement purposes. Such photos and
ÿ No information may be used in newsletters, newspaper stories, social Corrections ONLY
media or other reports/purposes describing the program. ÿ Yes I give Skills U permission to release my attendance records to
ÿ No my local jailer and the Kentucky Department of Corrections for
ÿ Yes I give this adult learning center staff permission to release my
the purpose of verifying my completion of academic goals as it
records to other educational institutions and appropriate
ÿ No relates to educational good time credit.
public agencies, as necessary.

4 *CURRENTLY RECEIVING: 5 *RACE 6 *OTHER STUDENT 7 *RELEASE OF

: INFORMATION: INFORMATION
ÿ Unemployment Insurance ÿ American Indian/Alaskan Native
ÿ Homeless
ÿ KAERS
ÿ Disability SSI ÿ Black, or African American
ÿ U.S. ÿ KY Career Center
4 ÿ Asian
ÿ TANF Citizen ÿ KCTCS
ÿ Native Hawaiian or Pacific Islander ÿ Veteran
ÿ SNAP ÿ Ministerial Association
ÿ White ÿ Prob. & Parole_____
ÿ Medicaid ÿ Immigrant
ÿ Employer________
ÿ DCBS/SNAP
8 *ETHNICITY ÿ Hispanic or Latino
*RACE: ÿ Other
ÿ Not Hispanic or Latino

ONLINE FORM Kentucky Adult Education July 2022

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ENROLLMENT INFORMATION (STUDENT SECTION CONT.)

BARRIERS OF EMPLOYMENT-Must be completed in the presence of staff (Check all that apply)
Individual with a Disability? ÿ Yes ÿ No

CATEGORY OF DISABILITY (Check all that apply)

ÿ Physical/Chronic Health Condition ÿ Physical/Mobility Impairment ÿ Mental or Psychiatric
ÿ Vision-related Disability ÿ Hearing-related disability ÿ Learning Disability
ÿ Cognitive/Intellectual Disability ÿ Participant did not disclose type of disability ÿ No Disability

Exhausting TANF within 2 Years? ÿYes ÿNo

Homeless Participant, Homeless Children and Youths or Runaway Youth? ÿYes ÿNo
Single Parent? ÿYes ÿNo
Low Income Status? ÿYes ÿNo
Cultural Barriers? ÿYes ÿNo
Foster Care Youth Status? ÿYes ÿNo
Ex-Offender? ÿYes ÿNo
Migrant and Seasonal Farmworkers? ÿYes ÿNo
Displaced Homemaker? ÿYes ÿNo
Long-term Unemployed? ÿYes ÿNo
Regular Transportation? ÿYes ÿNo
Custody of at Least One Child under the Age of 6? ÿYes ÿNo
*EMPLOYMENT STATUS *SECONDARY EDUCATION CREDENTIAL
ÿ Correctional Facility *Enroll
ÿ GED/High School Equivalency
ÿ Not in Labor Force Date:
ÿ High School Diploma
ÿ Employed but Notice Termination ÿ Other High School Equivalency
ÿ None Site:
ÿ Employed FT/PT
ÿ Unemployed ÿ Non U.S.-based High School Diploma

ENROLLMENT INFORMATION (STAFF USE ONLY)

*ENROLLMENT SOURCE *PROGRAM TYPE *ENROLLMENT SUBJECT

ÿ Community Partner ÿ Adult Education or ESL ÿ Reading

ÿ Math
ÿ County Jail ÿ AE/ESL Carry-Over Achievements
ÿ Court Ordered ÿ GED Ready/No initial test ÿ Language

ÿ Employer/Business SERVICE TYPE EXCLUSIONS

ÿ Media Influence
ÿ Adult Ed at the Workplace ÿ Corrections
ÿ Personal Referral (Word of Mouth)
ÿ Family Literacy ÿ Death
ÿ Post-Secondary School Referral ÿ Corrections
ÿ Active-Duty Military
ÿ Probation and Parole
ÿ EL/Civics ÿ Sick (Hospital for over
ÿ Secondary School Referral ÿ SNAP E&T Treatment
90 days)
ÿ State Institution
ÿ SNAP E&T Control
ÿ Walk-In (Not Referred) ÿ GO
ÿ WIOA Core Partner
ÿ Workplace Literacy
ASSIGNED STAFF *INTENT
ÿ Basic Skills Acquisition ÿ ÿ Learn English Language ÿ KESC
Gain Employment ÿ GED ÿ NCRC
ÿ Transition to College

______________________________________________________ _____________________________________

Student Signature Date

ONLINE FORM Kentucky Adult Education July 2022