Wellspring Adult education inquiry form

Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Is this a mobile phone *

Yes

No

Are you a U.S. citizen?

Yes

No

I don't know

If not U.S. citizen, are you authorized to work in the U.S.?

Yes

No

I don't know

Do you have a diagnosed learning, physical or mental disability?

Yes

No

I don't know

Have you ever had an IEP or 504plan in school?

Yes

No

I don't know

Is English your native language?

Yes

No

I don't know

Do you need assistance with learning English?

Yes

No

I don't know

Have you ever been involved with court or juvenile system?

Yes

No

I don't know

Are you a parent?

Yes

No

I don't know

Are you currently facing housing insecurity or homelessness?

Yes

No

I don't know

Are you or have you been in foster care?

Yes

No

I don't know

Do you or any members of your family receive SNAP benefits?

Yes

No

I don't know

Do you or any members of your family collect unemployment?

Yes

No

I don't know

Have you received free/reduced lunch within the past 2 years?

Yes

No

I don't know

Do you or any members of your family receive any type of public assistance (SSI/SSDI/TANF)?

Yes

No

I don't know

Do you or members of your family receive MassHealth benefits?

Yes

No

I don't know

Are you currently in school? *

Yes

No

Are you required to register for selective service? *

Yes

No

Martial Status *

Single

Married

Divorced

Widowed

Do you have children who live with you? *

YES Full Time

YES Joint Custody

NO

Employment Status *

Employed

Unemployed

Retired

Do you need assistance finding employment or a better job? *

Yes

No

Do you rely on your paycheck to support yourself? *

Yes

No

Do you currently feel secure in your ability to provide food for yourself and any dependents? *

Yes

No

Are you of Hispanic, Latino or Spanish origin? *

No, not of Hispanic, Latino or Spanish origin

Yes, Mexican, Mexican American or Chicano

Yes, Puerto Rican

Yes, Cuban

Yes, of another Hispanic, Latino or Spanish origin

How do you identify your race? *

Check one or more boxes

White

Black/African American

Chinese

Filipino

Japanese

Asian Indian

American Indian/Alaskan Native

Native Hawaiian

Korean

Vietnamese

Guamanian or Chamorro

Samoan

Other Asian

Other Pacific Islander

Other

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Phone

(###)

###

####

Which issues prevented you from finishing? *

Academics

Behavioral

Social

Other

How do you plan to get to Wellspring in Hull? *

Public Transportation

Walk

Drive

I need transportation

What will you do after you complete your education? *

College

Training Program

Enter Workforce