Neighborhood House Learner Intake
Complete the form to register for English, GED, job search & Computer classes
Last name *
First name *
Program needed *
(right now all our programs are online)
Required
If you want English class: what level
What time do you want class? *
Required
Address *
Street address, city & zip code (ex: 179 Robie St E, St Paul 55107)
Telephone number *
Birth date *
MM
/
DD
/
YYYY
Where were you born?
(your country)
What language(s) do you speak?
Gender
Clear selection
Email address
not required
Do you receive Public Assistance? *
If you receive Public Assistance, check what you receive:
Ethnicity
Employment *
Did you go to school in your country?
Clear selection
How many years did you go to school?
Clear selection
Did you go to school in the U.S.? *
What was the highest grade level completed?
Do you have a U.S. Diploma or GED?
Clear selection
Are you a US veteran?
Clear selection
How did you learn about our classes?
Please check this box after you read the statement below *
Required
Tennessen Warning / Privacy Notice
This information tells you how we may use the information from your application. It also says who we may tell this information, and what will happen if you choose not to provide it.

Why do we ask you for information?
We may ask you for information so we can:
• tell you from other persons with a similar name
• decide if/which services you can receive
• receive state and federal funds to help you
• let program funders know if Adult Basic Education has helped you

You are not required by law to provide this information. If you choose not to provide this information, we may not know if you are eligible for the program and may not be able to help you.

How will we use the data?
We may use it to prepare required reports, conduct audits, review eligibility and to find out how the program is helping you.

Who will we share the information with?
We will share the information with staff, allowed by law, who need it to do their jobs in: The MN Dept. of Jobs & Training; U.S. Depts. of Health & Human Services, Labor, Housing & Urban Development, and Agriculture; and software developer UrbanPlanet Software. We may share it with community-based agencies, local and state human service agencies, educational programs, and other agencies that help you. If you enroll in another MN Adult Basic Education program, your data will be shared with them.

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