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BMCC ADULT EDUCATION PROGRAMS REGISTRATION FORM

 


First Name           Last Name M.I.

Date of Birth:
Month Day Year                   Social Security Number:

Work Phone:   Home Phone:

Home Address
        Sex:
Gents
Ladies
Don't know

Immigrant?
Yes
No

Race/Ethnic Identity:
Native American Alaskan Native Asian Pacific Islander
African American Afro-Caribean Latino/a White(not Latino/a) Other

Employment Status
Employed Full-time
Employed Part-time
Unemployed 1 year or more and available to work
Unemployed less than 1 year and available to work
Not Available for employment

Receiving Public Assistance?
Yes No             If yes, enter Category     A=TANF B=ADCU C=HR H=HR O=Other
Case Number:      

Country of Birth:    

Initial Settlement in U.S.     State:   Month Day Year

Referral Source
A Another Student             B TV/Radio                . C Newspaper           D Friend or Relative
E Social Service Agency   F Education Program   G Training Program   H Recruiting Poster/Flyer
I GED Program              .   X Other, specify        

School-aged children
Do you have any Children? YesNo      .   Are you a single mother? YesNo
Total number of children under 21?     PreK Elementary School Junior High School High School

Highest Grade Completed   Years in U.S.Schools  

Prior Schooling in NYC None Elementary School Junior HighHigh School