South Suburban ABE Intake Form
100 7th Ave North
South St. Paul, MN  55075
Office:  651-306-3632

Please fill out the information boxes below to be added to the mailing list for the next session offered. This information is being collected by the ABE program assistant and will not be shared outside of the ABE office.
Sign in to Google to save your progress. Learn more
Class options *
Last Name *
First Name *
Middle Name
Social Security Number
Street Address, City, Sate, Zip *
Primary Phone Number *
Email Address *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Country of Birth *
Primary Language
Hispanic/Latino *
Race *
Work Status *
Public Assistance *
Highest Formal Education Level *
Education Location *
NRS Tracking - mark as many as apply *
Required
NRS Program- mark as many *
Emergency Contact Name (First & Last) and Phone Number *
Tennessen Warning/Privacy Notice This form tells you how we may use the information from your application and participation in this program. It also tells with whom we may share this information, and what will happen if you choose not to provide it.Why do we ask you for program information?We may ask you for information so we can:• tell you from other persons with a similar name• decide if you can receive our services• decide which services you can receive• receive state and federal funds to help you• let program funders know if Adult Basic Education has helped youYou are not required by law to provide this information. If you choose not to provide this information, we may not know whether you are eligible for the program and may not be able to help you. Providing false information can lead to removal from the program.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.Social Security Numbers You do not have to provide your Social Security number. Federal Privacy Act and Freedom of Information Act dictate the use of this number. We may use it for computer matches, program reviews, improvements and audits.How long will we keep the information?After you leave the program, we will keep your file until state and federal laws let us destroy it. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of TriDistrict Community Education. Report Abuse
Google Forms