23-24 Brainerd ABE Intake Form
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1)  Tennessen Warning, We needed to ask you for the following information for our program records: Name, birth date, gender, race/ethnic group, employment status. We ask for your social security number to track students who have a job goal. You do not need to give us your SSN, but it would help our program if you do. We may share some information with teachers and other staff of Brainerd Public Schools. We report this information to the MN Department of Education for annual reporting and funding. We will only share this information with other organizations if you give us permission. I have read this:* *
2) Have you ever been a Brainerd ABE student?
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3) Today's Date
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4) Last Name *
5) First Name *
6) Middle Name
8) Street Address *
9) City, State *
10) Zip Code *
11) County *
12) ISD (Where you attend school)
13) Primary Phone *
14) Cellphone Company.  (By having your cellphone provider, I can send you texts from my email; therefore making communication easier).
16) Date of Birth *
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MM
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17) Gender *
18) Country of Birth *
19) Primary Language *
20) Hispanic/Latino *
21) Race *
22) Work Status *
23) Public Assistance *
24) Highest Formal Education Level *
26) Education Location *
27) NRS tracking-***choose all that apply*** *
Required
Personal Goals: ***choose all that apply*** *
Required
29) Emergency Contact Name
30) Emergency Contact Phone number
31) Comments or Questions
Once completing this form, remember to email Barb at  barbara.gmitrobest@isd181.org  to set up an Orientation Meeting (this is where you can sign up for classes and get your Personalized Education Plan).  You MUST email Barb to start classes!
***You MUST email Barb to start classes and be fully enrolled in the program!!!***
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