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Learner Demographics
Today's Date *
MM
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DD
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Learners Name *
Learner Age *
Learner Address *
First Time Student at SBLC? *
Learner Race: *
Learner Gender: *
Learner Current Residence: (choose one) *
Learner Living Situation: (choose one) *
Employment: *
Type of Employment/Not in Labor Force: *
Learner In school? (outside of SBLC) *
Learner Pregnant? *
Learner Marital Status: *
Learner receive SSI? (Retired) *
Learner receive SSDI? (Disabled) *
Learner annual family income *
Medicare? *
Medicaid? *
Does the learner speak English well? *
English *
Additional information about language:
Learner History of or current substance abuse? *
Learner History of or current mental health issues? *
Learner History of or current trauma issues? *
Learner History of or current tobacco use? *
Program Enrolled? *
How did you hear about us? *
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