Program Intake Form Step 1 of 7 14% Name* First Last Email* Date of Birth* Date Format: MM slash DD slash YYYY Social Security Number (xxx-xx-xxxx)*This site is secure. SSN required for all new students. Returning students may use 123-45-6789. If you do not wish to supply your SSN at this time, please call 410-625-4215.Race*Amer. Indian/Alaskan NativeAsianBlackNative Hawaiian/Other Pacific IslanderWhiteEthnicity*Hispanic or LatinoNot Hispanic or LatinoNative Country*United StatesAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweNative or First Language*Sex at Birth (Required for State Funding)*MaleFemale Your Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneDo you have any children?*YesNoHow many children do you have in each age group?0-5*01234566-13*012345614-21*012345621+*0123456Marital Status*SingleMarriedWidowedDivorcedSeparated Please check the boxes for all you have access to* Internet Smart Phone Windows 10 Based PC or Laptop Apple PC or Laptop iPad Tablet other than iPad What is your comfort level with the tech items listed above?*ExpertVery ComfortableSomewhat Comfortable, but willing to learn moreUncomfortable, but willing to learnUncomfortable, and I have no interest in leaningPlease check ALL of the possible class options you may be interested in. All days and times listed may not be available every session.* In Person Monday 9-12 In Person Tuesday 9-12 In Person Wednesday 9-12 In Person Thursday 9-12 In Person Monday 5:30-8:30 In Person Tuesday 5:30-8:30 In Person Wednesday 5:30-8:30 In Person Thursday 5:30-8:30 In Person Saturday 9-12 In Person Saturday 12-3 Online Monday 9-12 Online Tuesday 9-12 Online Wednesday 9-12 Online Thursday 9-12 Online Saturday 9-12 Online Saturday 12-3 Online Tuesday 5:30-8:30 Online Wednesday 5:30-8:30 Online Thursday 5:30-8:30 Asynchronous (No set meeting times. Teacher and learner communicate and create plan.) Preferred Site(s) for in person classes. Check all that apply* South Baltimore Learning Center | 28 E Ostend 21230 Clay Pots | 1635 W Pratt St 21223 University of Maryland | ?????? Enoch Pratt Library | ???? Branch Last High School or GED Program Attended*Reason for Leaving High SchoolWhat is the highest grade you COMPLETED? (If you left school during 10th grade, please put 9th)*No Formal Schooling1st2nd3rd4th5th6th7th8th9th10th11th12thReason you want to enrollEarn High School Diploma by Taking GED TestsEarn High School Diploma by Completing the National Eternal Diploma ProgramI already have a diploma, but I want to improve my skills (Upskilling)I DO NOT want a High School Diploma, but I want to improve my skills (Upskilling)Were you in special education?* Yes No Did you receive a HS diploma or alternate credential?* Yes No Did you go to school in the USA?* Yes No Did you receive a GED?* Yes No Did you attend college, but not receive a degree?* Yes No Did you complete college or a professional degree?* Yes No What is your employment status? If you are receiving Unemployment Benefits, please select Unemployed.*Part timeFull timeUnemployedRetiredDisabledNot in Workforce (not working AND not looking for work)Employed with Separation NoticeEmployerEmployer Address and Phone NumberHourly wage?Does your employer know you are enrolled in classes?* Yes No How does you employer pay you?In cashIn a paycheckThrough direct depositDo you have current barriers to employment?* Displaced Homemaker (Took care of family member w/o pay & supported by another person) Low Income Ex-Offender Cultural Barriers Exiting TANF (Temporary Assistance for Needy Families) within Two Years Homeless Long Term Unemployed (27 weeks or longer) Low Literacy Levels Disabled Foster Care Youth Single Parent (Guardian) No Barriers to Employment Not looking for Employment Are you currently receiving public assistance through any of the following programs?* No Temporary Cash Assistance Food Stamps DSS Disability WIC SSI/SSDI Do you need any type of assistance? (i.e. food stamps, counseling, heath or housing resources, other)*How did you find out about S.B.L.C.?*University of Maryland BaltimoreMOEDUnited WayAll-State Career SchoolsCommunity Engagement CenterFriend/FamilyEmployerLiteracy HotlineFlyer/BrochureSocial MediaRadio or TV adHigh School StaffWebpageNewspaperDo you have a medical condition or illness that you would like us to know about?*Do you have a PROBATION OFFICER OR CASE MANAGER that we should know? If so, PLEASE PROVIDE INFO BELOW . Include Agency, Contact Name and Phone NumberNumber Living in House & Total Household Income*Please select the option that states the number of people in your household, including you, and the closest to the total yearly income of everyone added together.1 Person $21,5001 Person $35,3501 Person $52,8501 Person Over $52,8502 Persons $24,2502 Persons $40,4002 Persons $60,4002 Persons Over $60,4003 Persons $27,3003 Persons $45,4503 Persons $69,9503 Persons Over $69,9504 Persons $30,3004 Persons $50,5004 Persons $75,5004 Persons Over $75,5005 Persons $32,7505 Persons $54,5505 Persons $81,5505 Persons Over $81,5506 Persons $35,1506 Persons $58,6006 Persons $87,6006 Persons Over $87,6007 Persons $37,6007 Persons $62,6507 Persons $93,6507 Persons Over $93,6508 Persons $40,0008 Persons $66,7008 Persons $99,7008 Persons Over $99,700Photo Release: I give SBLC permission to take my picture during the class session that may be used for publicity purposes only including the SBLC website and/or Facebook page.*YesNoDo you have any Military Service experience?*YesNoDo you file taxes as "head of household" instead of single or married?*YesNo Your Goals*Please select each item below that is a goal for you. Become Employed Leave Public Assistance Remain Employed Obtain High School Diploma By Taking GED Tests Obtain High School Diploma By Completing The National External Diploma Program Explore Career Options Enter Military Service Enter a Pre-Apprenticeship Program Enter an Apprentice Program Improve Computer Skills Improve Math Skills Improve Reading Skills I understand that typing my name below is legally the same as signing in person.*YesNoI, a student at a postsecondary educational institution or a student age 18 years or older, consent to the release of personally identifiable information from my education records.I understand that the records to be disclosed include my social security number and other personally identifiable information from my education records. I acknowledge that the purpose of the disclosure is to assist the Maryland Department of Labor, in obtaining and reporting information concerning the placement and retention of students in employment as required by Section 212 of the Adult Education and Family Literacy Act. This information may not be redisclosed to others and will be destroyed as soon as all statistical analysis has been performed, or when the information is no longer needed, whichever date comes first. Please Type your name below:*PhoneThis field is for validation purposes and should be left unchanged.