NYHTC GED REGISTRATION CLASS CODE (if known) INSTRUCTOR Myles Ephraim Armando Hernandez Betty Paysner Class category English (ESOL) "GED"/TASC in English "GED"/TASC in Spanish Last Name * First Name * Middle Name SSN (last 4 digits or optional) Date of Birth MM DD YYYY Street Address Apt # City State Zip Work Phone (###) ### #### Home Phone (###) ### #### Cell Phone (###) ### #### Email * Gender Choose not to identify Female Gender Neutral Male Race/Ethnicity African American|African|Afro-Caribbean Asian|Pacific Islander or Native Hawaiian Latino or Hispanic Native American or Alaskan Native White (non Latinx) Other Country of Birth Date of U.S. Settlement (if applicable) Immigrant? Yes No Refugee? Yes No Employment Status Employed Full Time Employed Part Time Not available for employment Received a-1099 Form for work Self-Employed Unemployed If Unemployed, how long? Employer's Name Job Title Work Location BK BX MN QN SI Pay Period Hourly Yearly Other Pay Rate Average Hours Worked Weekly Marital Status Divorced Domestic Partnership Married Never Married Other Separated Widowed Number of Adults in Household Number of Children in Household Annual Household Income $0 - $14,999 $15,000 - $24,999 $25,000 - $34,999 $35,000 - $44,999 $45,000 - $54,999 $55,000 - $64,999 $65,000 - $74,999 $75,000 + Veteran (or living with veteran)? Yes No If Yes, Who? Public Assistance Aid to the Blind or totally disabled Food Stamps MEDICAID Not receiving Public Assistance Old-aged Assistance Other Refugee Cash Assistance Safety Net Section 8 Assistance SNAP Participant Social Security Disability (SSD) Supplemental Security Income (SSI) TANF Case Number Are you Collecting Unemployment benefits? Yes No Highest education level achieved in U.S. 12th grade (no diploma) 9th-11th grade Associate degree High School Diploma Less than 9th grade Master’s|Graduate Degree Other PhD|Doctorate Some College (no degree) Undergrad|Bachelor’s|Baccalaureate If other: Highest credential from Other Country 12th grade (no diploma) 9th-11th grade Associate degree High School Diploma Less than 9th grade Master’s|Graduate Degree Other PhD|Doctorate Some College (no degree) Undergrad|Bachelor’s|Baccalaureate If other: Union Member/Family of Member? Member Family of member None of above Union Affiliation (if any) Union Local Is Student the Parent or Guardian of Children? Yes No Single Parent? Yes No If yes, enter Number of Children at Each Level: Please indicate number of children in applicable categories: PreK | Elem | JHS | HS | College Population Categories Disabled Dislocated Workers Displaced Homemakers Employed at 200% of Poverty Level Enrolled in Other Education|Training Head of Household High School Graduate or Equivalent Homeless In Correctional Facility Learning Disabled Low Income Non Native English Speaker NYCHA Resident Other Other Institutionalized Resident of Public Housing Veteran Referral Source Another Student Church Education program Employer Friend or Relative GED Program Library Newspaper One-Stop Other Other Literacy Organization Phonebook Radio Recruitment Poster|Flyer Returning Student Social Service Agency Training Program TV Web Site Workers Union Short-term Goals Earn Secondary School Diploma Earn GED Certificate Enter Post-Secondary Education Enter Training Improve Basic Literacy Skills Improve Current Job Improve English Literacy Skills Obtain a Job Other Retain Current Job Other Student Goals Get involved in Children’s Education Get involved in Children’s Literacy Activities Get involved in Children’s Community Activities Obtain Citizenship Skills Reduce Public Assistance Thank you!