SMARTT STUDENT INTAKE FORM FOR FY2016
BASIC INFORMATION:
® Previously Enrolled (Y/N) ____________
® First Name:
® Site Name: ___________________________
® Middle Name: ________________________
_______________________________________
® Last Name: ___________________________
®Intake Date: _____ / ______/ _______
MM
DD
YEAR
®Previous Name: ________________________
_________________________
 Not Provided
® Date of Birth:
______ / ______/ _______
MM
DD
YEAR
® City of Birth: ______________________________
®SSN: __________ - ________ - ______________
®Gender:
 Male  Female
 Not Provided
®Ethnicity:
Hispanic/Latino:  Yes
 No
®Race: (can select more than 1)
 American Indian or Alaska Native
 Native Hawaiian or Other Pacific Islander
®Immigrant:  Yes  No
 Asian
 White
 Black or African American
®Country of Birth:
®Mandated Enrollment:  Yes  No
®Referred By/ Heard About Program From:
 Another ABE Program
 Another Student
 Community Organization
 Court/ Probation Officer
 Department of Transitional Assistance (DTA)/Welfare
 Employer
 Flier/Brochure/Poster
 Friend/Relative
 Head Start
 Library
 Literacy Hotline
 MA Rehabilitation
 Military Recruiter
 Newspaper
 One Stop Career Center /Unemployment Office
 Program Website/Facebook
 Radio or Television
 Reintegration Counselor
 Not Applicable
®First Language: ____________________________________
®Primary Language Spoken at Home: _______________________________________
®Release of Information Form Signed (revised 5/11/2010)
 Yes
 No
Page 1
CONTACT INFORMATION:
Home
Last Known Address
Last Name:
First Name:
(Name is already entered in Basic
Information on page 1)
M. Initial:
®Address:
®City:
®State:
 Check if last known address is the same as
current home address
®Zip Code:
®Phone
Number:
®E-Mail:
(or N/A)
EDUCATION:
®Last Grade Completed
in Foreign Country:
®Last Grade Completed in US:
®Schooling Completed:
 No High School Diploma
 US High School Diploma
 High School Equivalency
 ADP/EDP
 Equivalent of HS Diploma in
Another Country





Some College but no Degree
Associate Degree (2 years beyond H.S.)
Bachelor Degree (4 years beyond H.S )
Masters Degree (1 or more years beyond BA)
Doctorate Degree
Page 2
EMPLOYMENT AND HOUSEHOLD:
®Employment Status:
 Employed
 Unemployed and Not Looking for Work
 Homemaker
®Occupation: (required if employed)
®Employment Job Type:
 Full Time (30 or more hrs/wk)
 Temporary Jobs


Unemployed and Looking for Work
Retired or Otherwise Not Looking for Work
(See dropdown list on ACLS Website- SMARTT section)
 Part Time ( less than 30 hrs/wk)
 Multiple Jobs
®Public Assistance:
 TAFDC (Transitional Aid to Families with Dependent Children)
 EAEDC (Emergency Aid to the Elderly, Disabled and Children)
 EA (Emergency Assistance)
 SNAP (Supplemental Nutrition Assistance Program)/Food Stamps
 SSI ( Supplemental Security Income)
 Women, Infants, and Children Program (WIC)
 None
 Other
®Homeless:
 Yes
 No
®Children Under 18 Living in Same House
®Single Parent/Guardian/Caregiver:  Yes  No
 Yes
 No (Child Birth Year Required if Yes)
®Children Birth Year:
®In School (Pre
Kindergarten): (Y/N)
SCHEDULING AVAILABILITY:
®Available for Classes in Summer:
 Yes
 No
®Total Available Hours Per Week: (including class hours)
®DISABILITIES AND ACCOMMODATIONS:
This Adult Basic Education Program does not discriminate on the basis of disabilities. Students/Applicants may,
but do not have to disclose disabilities. Applicants who disclose disabilities may be entitled to reasonable
accommodations.
1) Does the student/applicant understand that he/she is not required to disclose
his/her disability?
2) Does the student/applicant wish to disclose a disability?
3) Does the student/applicant understand that self-disclosing a disability makes
him/her eligible for reasonable accommodations?
4) If Yes to #3, does the student/applicant wish to request any specific
accommodations?
Updated 6/11//15
 Yes
 No
 Yes
 Yes
 No
 No
 Yes
 No
Page 3