Perkins/Special Populations Program Assessment
As a student enrolled in a career/technical program, you may be eligible for special support services to enhance your success in your program of study. In order to determine eligibility for services, please complete the following survey. All answers and surveys will be kept in strictest confidence. Participation in this survey is strictly voluntary.
Name
First Name
Last Name
Student ID Number
Street Address
Street Address Line 2
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Email address
example@example.com
Type of Disability:
Autism
Behavior/Emotional Disorder
Deaf/Blind
Hearing Impaired
Health Impairment
Mental Impairment
Physical Impairment
Learning Disability
Speech Impairment
Traumatic Brain Injury
Student with Disability Not in Special Ed
Other
Do you receive any type of financial aid based on need? If yes please check the boxes below:
Yes
No
Type of Aid:
Pell Grant
Map Grant
SEOG Grant
WIA/WIOA Assistance
Public Aid
Department of Human Services Assistance
Office of Rehabilitation Services Assistance
Other
Are you a single parent with dependent child/children? The term single parent means an individual who (A) is unmarried or legally separated from a spouse and (B) has a minor child or children for which the parent has either custody or joint custody or is pregnant:
Yes
No
Are you an Out of Workforce Individual? The term "Out of Workforce" means an individual who has worked primarily without remuneration to care for a home and family and for that reason has diminished marketable skills or is a parent whose youngest dependent child will become ineligible to receive assistance under part A of title IV of the Social Security Act (42U.S.C. 601 et seq.) not later than 2 years after the date on which the parent applies for assistance under such title; and is unemployed or underemployed and is experiencing difficulty in obtaining or upgrading employment:
Yes
No
Are you enrolled in or have you completed a Developmental English, Reading, or Math Course? (Eng 105, Writ 101, Read 101, 106, 108, Math 101,106,108,109):
Yes
No
Is English your native/primary language?
Yes
No
Are you currently in, or have you aged out of the foster care system?
Yes
No
Are you an individual preparing for a non-traditional field? The term "non-traditional" fields means occupations or fields of work, including careers in computer science, technology, and other current and emerging high school occupations, of which individuals employed in each such occupation or field of work. For example, a male enrolled in Cosmetology or Nursing, or a female enrolled in Information Technology, Welding, or Diesel Technology programs.
Yes
No
Are you Homeless? The term "homeless" refers to a) Homeless children and youths means individuals who lack a fixed, regular, and adequate nighttime residence. This term includes (1) Children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; or are abandoned in hospitals. (2) Children and youths who have a primary night time residence that is a public or private place not designated for or ordinarily used as a regular sleeping accommodation for human beings. (3) Children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus ,or train stations, or similar settings; and (4) Migratory children (as defined in section 1309 of the Elementary and Secondary Education Act of 1965, as amended), who qualify as homeless because the yare living in circumstances described in this definition.
Yes
No
I need tutoring assistance.
Yes
No
I need special instructional resources:
Yes
No
I need note takers:
Yes
No
I need special or adaptive equipment devices:
Yes
No
I am interested in receiving free access to SIC's new career services including career exploration, resume writing, scholarship search, etc.
Yes
No
Number of Semesters on Campus
1-2
3-4
4+
Other
What are your Educational Goals:
To complete a certificate
To complete a 2-year college degree
To complete a 4-year college degree
To upgrade my job skills for the workplace
Unknown or to take courses for personal development
Submit
Should be Empty: