Adult Education Program Intake Assessment Form

Form completion is required for ALL adult learners and ALL programs.

Use the TAB key or click your mouse to move through the form. Do not use the enter key.

Student Name
Enter name EXACTLY as it appears on your ID
Student Data

Student Contact Information
Student Address
Emergency Contact Information

Student Status & Special Populations

Special Populations/Needs

Special Accommodations Notice (Optional disclosure) - If you have a disability and desire any special accommodation for instruction or testing, it is your responsibility to notify the program administrative office and provide professional documentation of disability. A disability is a physical or mental impairment that substantially limits one or more of a person's major life activities. If you do not wish to disclose your disability, leave the question below blank.


Please verify all information before continuing. You will not be able to view or modify this information later.