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Aspire
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Student Registration Form
Date
*
+
New Student?
*
Yes
No
Returning Student?
*
Yes
No
Student Information
Social Security #:
*
Birth Date:
*
+
Age at Enrollment:
*
Last Name
*
First Name
*
Middle Initial:
Other Names:
Mailing Address:
*
City:
State:
Zip:
County:
*
Home Phone:
*
Cell/Mobile Phone:
*
Please Upload Photo ID
Please Upload Proof Of Residence
Email Address:
*
Please select your preferred method of contact:
*
Phone
Mail
E-Mail
Emergency Contact Person:
*
Emergency Contact Phone:
*
Allergies:
*
Medical Conditions:
*
Gender
*
Female
Male
ETHNICITY
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Hispanic
BARRIERS
Cultural Barriers
Disabled
Displaced Homemaker
English Language
Learner
Lot-term Unemployed
Low Income
Low Literacy Level
Ex Offender
Exiting TANF Within Two Years
Foster Care Youth (incl. aged out)
Homeless/Runaway Youth
Migrant Farmworker
Seasonal Farmworker
Single Parent or Guardian
WORK STATUS
*
Employed - Full-time
Employed - Part-time
Employed - Received Notice of Separation
Unemployed - Not Looking for Work
Unemployed - Unavailable for Work
Unemployed
Retired
Registered on OhioMeansJobs?
*
Yes
No
PUBLIC ASSISTANCE
*
Yes - SNAP (Food Stamps)
Yes - TANF/Cash Assistance
Yes - Other
No
Other Public Assistance - Please specify:
*
IMMIGRATION INFO
Immigrant or Refugee
If checked enter
Country of Birth:
Do you have an F-1 Visa?
*
Yes
No
DISABILITY
*
🛈
No
Yes
If yes, please list needed accommodations:
Referral Source
Employer
Family/Friend
Attended Before
Newspaper/TV/Radio Ad
Brochure/Flyer
Department of Job and Family Services/OhioMeansJobs Center
Opportunities for Ohioans with Disabilities (OOD)
Court/Corrections/Probation Officier
Internt- Agency website, Facebook, etc.
Other
If other Referral,
Please specify:
Education
Highest Degree or Level of School Completed:
*
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 9
Grade 10
Grade 11
Grade 12 (No Diploma)
Secondary School Diploma
Secondary School Recognized Equivalent
Some Postsecondary education, no degree
Postsecondary or professional degree
School Location:
*
U. S. Based School
Non-U. S. Based School
REASON(S) FOR ATTENDING THIS PROGRAM
(Check all that apply)
*
Improve Job Prospects
Obtain a Secondary School Diploma/High School Equivalency
Obtain a Driver's License
Qualify for Training/Military
Help Children
Social/Self
Qualify for College
Required
Reading Competency
Math Competency
Other (Please specify):
Other (Please specify):
(ESOL Students Only)
Learn Better English
Achieve Citizenship Skills
Vote or Register to Vote
Increase Involvement in Community Activities
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