Learner Registration Form

Date of Birth

Month:

Day:

Year:

Street Address:

City:

State:

Zip Code:

Gender:

Phone Number:

Email:

Native Country:

Native Languages:

What language do you speak most at home?

Other

What is your living situation?

How long have you been in short term housing?

Short Term

Other

Homeless/Runaway

What is your Marital Status?

What transportation do you use?

Other Transportation

Treatment/Rehab Status

Have you gotten help for Substance Abuse within the past year?

Have you gotten help for Mental Health within the past year? (In-Patient or Out-Patient treatments, Therapy, Medications, etc.)

Goals

Do you want a new job?

Do you want to get your HSE diploma?

Do you want to go to college/university?

Do you want to take a job certification course or training?

Do you want to help your child with their homework more?

Do you want to get more involved in your community?

Do you want to be more financially stable and leave public assistance?