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Student ID Name:(Required) Please carefully type your legal name .
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Are you a currently a student at any high school in the state of Indiana?(Required) In case of an emergency, what is your preferred hospital? Student Goals – I would like to: Please select the goals you would like to accomplish with us. Check all that apply.
If you have any other goals or needs, please type those here, as well as anything else you would like our staff to know about you.
Address:(Required)
In which county do you live?(Required) Select your county of residence: Select Your County PUTNAM HENDRICKS MORGAN MONROE OWEN CLAY PARKE MONTGOMERY ADAMS ALLEN BARTHOLOMEW BENTON BLACKFORD BOONE BROWN CARROLL CASS CLARK CLINTON CRAWFORD DAVIESS DEARBORN DECATUR DEKALB DELAWARE DUBOIS ELKHART FAYETTE FLOYD FOUNTAIN FRANKLIN FULTON GIBSON GRANT GREENE HAMILTON HANCOCK HARRISON HENRY HOWARD HUNTINGTON JACKSON JASPER JAY JEFFERSON JENNINGS JOHNSON KENTUCKY KNOX KOSCIUSKO LAGRANGE LAKE LAPORTE LAWRENCE MADISON MARION MARSHALL MARTIN MIAMI NEWTON NOBLE OHIO ORANGE PERRY PIKE PORTER POSEY PULASKI RANDOLPH RIPLEY RUSH SAINT JOSEPH SCOTT SHELBY SPENCER STARKE STEUBEN SULLIVAN SWITZERLAND TIPPECANOE TIPTON UNION VANDERBURGH VERMILLION VIGO WABASH WARREN WARRICK WASHINGTON WAYNE WELLS WHITE WHITLEY
Please upload a favorite photo of yourself so that we can use it for your student profile. Because we are using this for your student ID, please include only your head and shoulders in the image.
Are you a US Citizen?(Required) We accept ALL students, regardless of which citizenship status you choose. Choosing NO will not prevent you from enrolling with us.
Veteran Status:(Required) Please select the statement that describes you.
Country of Birth:(Required) Select your native country: UNITED STATES AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA, PLURINATIONAL STATE OF BONAIRE, SINT EUSTATIUS AND SABA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA COTE D'IVOIRE (IVORY COAST) CROATIA CUBA CURACAO CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISLE OF MAN ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI NORTH KOREA (DPRK) SOUTH KOREA KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT BARTHELEMY SAINT HELENA, ASCENSION AND TRISTAN DA CUNHA SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN (FRENCH PART) SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SINT MAARTEN (DUTCH PART) SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SOUTH SUDAN SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA, BOLIVARIAN REPUBLIC OF VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE KOSOVO SCOTLAND VIETNAM YUGOSLAVIA Ivory Coast TIBET MAURITANIA NORTH MACEDONIA CABO VERDE ESWATINI
Date of Birth:(Required) Gender:(Required) Ethnicity:(Required) NOTE: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race, refers to Hispanic ethnicity.
Race:(Required) Please select all that apply.
Name of Emergency Contact:(Required) Who can we contact if we cannot reach you?
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Employment Information Choose the statement that best describes your employment status.(Required) Date of Hire:(Required) If you do not remember the exact date you were hired, you can choose the date that is your best estimate of when you were hired.
Educational Information Educational Status:(Required) Please check the highest level of education you have completed.
Last Grade Completed:(Required) Please select the highest grade level (1-12) that you completed. *If you have completed education beyond high school, choose 12 as your last grade level completed.
Previous Schooling Location:(Required) Where did you complete most of your previous education?
School Attendance Status at Entry:(Required) Select the option that BEST describes your current school situation:
Household Information Method Found:(Required) Please select the statement below that best describes how you first learned about our program.
Select one: FRIEND/RELATIVE/ACQUAINTANCE ADULT EDUCATION PROGRAM / SCHOOL EMPLOYER TV OR RADIO FLYER OR BROCHURE BROCHURE, FLYER COURT REFERRAL OTHER
Demographics Do you any have physical, mental, or learning impairments?(Required) Do you live in an urban area (inside city)?(Required) Do you live in a rural area (outside city)?(Required) Do you currently receive public assistance?(Required) Organizations such as Temporary Assistance For Needy Families (TANF), SNAP (food stamps), SSI and WIC are examples of public assistance.
Do you have a low level of income?(Required) A YES response means that you do not believe you have enough income to pay your bills.
Are you a displaced homemaker?(Required) A YES response means you were previously a stay at home mom or dad, but you are now seeking work due to a change in your household situation.
Are you a single parent?(Required) Are you a dislocated worker?(Required) A YES response means that you were laid off or lost your job due to the company moving away.
Are you a dependent yourself, or do you claim to have dependent(s) in your household?(Required) A YES response means that either someone claims you as a dependent OR you claim to have dependent(s) yourself.
Household Size: How many people live in your household, including yourself?(Required) Annual Family Income (How much is your family income in one year?)(Required) We accept ALL students, regardless of family income.
Are you currently, or have you ever, been in foster care?(Required) Are you considered to be homeless, or are you a runaway?(Required) A YES response means that you DO NOT have a permanent, regular nighttime residence (other than a vehicle, a shelter, or temporarily staying with a friend).
Do you speak a language other than English at home?(Required) What is the language you first learned as a child?(Required) Select your first language. Afrikaans Albanian Amharic Arabic Armenian Assamese Azerbaijani Bangla Bosnian Bulgarian Burmese Cantonese Catalan Chinese Croatian Czech Danish Dari Dutch English Estonian Fijian Finnish French German Greek Gujarati Haitian Creole Hebrew Hindi Hmong Daw Hungarian Icelandic Indonesian Inuktitut Irish Italian Japanese Kannada Kazakh Khmer Korean Kurdish Lao Latvian Lithuanian Malagasy Malay Malayalam Maltese Maori Marathi Nepali Norwegian Odia Pashto Persian Polish Portuguese Punjabi Querétaro Otomi Romanian Russian Samoan Serbian Slovak Slovenian Spanish Swahili Swedish Tagalog Tahitian Tamil Telugu Thai Tigrinya Tongan Turkish Ukrainian Urdu Vietnamese Welsh Yiddish/Pennsylvania Dutch Yucatec Maya
We understand that there are some circumstances that make it difficult to come to school or get a job. We have many resources that can help you with those difficulties. Please select any of the statements listed below that apply to you, because we may be able to help!(Required) Select all statements that apply to you.
Are you a migrant/seasonal farm worker?(Required) Are you an active military member?(Required) Are you involved in a Vocational Rehabilitation agency? If you don’t recognize any of these choices, select NO or UNKNOWN.
Do you utilize Wagner Peyser Employment services?(Required) Wagner-Peyser employment services are federally-funded Unemployment Services, which connects employers with job seekers.
Ex-Offender:(Required) Have you ever been convicted of a crime?
Cultural Barriers to Employment:(Required) Do you have any cultural barriers that affect your job opportunities?
INTERLOCAL ASSOCIATION WORK EXPERIENCE INTERNSHIP
I herby acknowledge that I have chosen to participate in a work experience program, organized and operated by Interlocal Association. I understand that COVID-19 has
been declared a worldwide pandemic by the World Health Organization and that it is extremely contagious and is spread mainly from person to person contact. By signing this waiver, I acknowledge that by participating in the work experience program I will be required to follow Reopen Indiana policies and guidance set forth by Governor Holcomb.
I voluntarily agree, to assume the risk and accept sole responsibility that I may be exposed to or infected by COVID-19 by participating in the work experience program and that such exposure or infection may result in personal injury, illness, permanent disability and death. I also exempt, release and indemnify Interlocal
Association, its board members, instructors, employees, students, fimders, host worksites and volunteers from any and all cause of action, liability claims, and demands whatsoever. I will not hold Interlocal Association liable for any injury (including but not limited to: personal injury, disability and death), illness, damage, loss, claim, liability or expense of any kind that I or my family may experience or incur in connection with my participation in the work experience program. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of Interlocal Association, its employees, board members, participants, funders, host work sites, volunteers, and representatives whether a COVID-19 infection occurs before, during, or after participation in any Interlocal Association work experience or other progrannuing
service. Consent to Release of Information:(Required) Photo Release We love to celebrate success with our students, and we often do that through pictures, articles, slideshows, and other fun media. In order for you to participate in that, we will need your permission to use your photo.
I grant this adult ed program, its representatives and employees the right to take and/or use provided photographs of me in connection with documents and promotional materials published by the same. I authorize this adult ed program, its representatives and employees, to use and publish the same in print and/or electronically.
I agree that Area 30 Adult Education may use such photographs of me, with or without my name, for purposes including training and instruction manuals, promotional materials, and electronic documents.
Student Photo Release:(Required)
INTERLOCAL ASSCOIATION WPRK EXPERIENCE/INTERNSHIP RULES AND CODE OF CONDUCT Typing your name in the field(s) below will constitute your electronic signature(s) for the above provided information. Please verify that all information is accurate and that you agree before you sign. Applicants who are under 18 years of age will require a parent/guardian signature as well.
Parent Consent to Release of Information:(Required) 
