PROSPECTIVE LEARNER INFORMATION FORM MR./MRS./MS.* First Middle Last ADDRESS* BIRTH DATE* MM slash DD slash YYYY PHONE NUMBER*WORK* S.S # INTERVIEWED BY NUMBER IN HOUSEHOLD* EMAIL* HOW DID YOU HEAR ABOUT US?* Family Friend Website Telephone Call Center’s Sign Attorney or Agency I am a returning learner Other Other ASSISTANCE PROGRAMS* TANF (Texas Assistance to Needy Families) SSI (Supplemental Security Income) SSDI (Social Security Disability Insurance) Veteran’s Compensation Food Stamps General Assistance Day Care Voucher School Lunch Medicaid Do Not Receive Any Assistance EMPLOYMENT STATUS:* Employed Unemployed Public Assistance Retired Student Social Security HOME LANGUAGE* TOTAL INCOME FOR HOUSEHOLD $* PREFERRED CLASS DAYS & TIMES* Morning Afternoon Evening Mon. Tue. Wed. Thur. Fri. TYPE OF LEARNER (Complete By Office) ABE Citizenship HSE Barton ESL Employment Preparation/Job Readiness NameThis field is for validation purposes and should be left unchanged.
