Spreadsheet: 048311e6-1fce-455e-9b05-2535f5ae0665
Sheet: Sheet1

[Program Name] | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | UTopia #:____________________ | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9
[Program Address] |  |  |  |  | Date Entered:____________________
Student Registraton/SEOP Data Collection 2008-2009 |  |  |  |  | Entered:     SEOP       Test Scores       Contact hours
New Student / Returning Student |  |  | Date (fecha):________________ |  |  | SS#_______________________________
 |  |  |  |  |  | ([NAME])
Last Name |  |  | First Name |  |  | Middle Initial |  | Maiden Name
Apellido |  |  | Nombre |  |  | Secundo nom. |  | Apellido de soltera
[NAME] (month/day/year) |  |  | Age / Edad |  |  |  |  | Sex     Male / Female
[NAME] (mes/dia/año |  |  | 18        19-24         25-44         45-59          60+ |  |  |  |  | Sexo   hombre / mujer
Address |  |  |  | City |  |  | State | Zip Code
Direccion |  |  |  | Cuidad |  |  | Estado
Home Phone |  |  | Cell Phone |  |  | email
Teléfono de casa |  |  | Teléfono celular
Employer |  |  |  |  |  | Work Phone
Empleador |  |  |  |  |  | Teléfono de trabajo
Name of Emergency Contact |  |  |  |  |  | Emergency Contact Phone #
Nombre de contacto emergéncia |  |  |  |  |  | Teléfona de contacto emergéncia
Ethnic Status ([NAME]) |  |  |  | [NAME] |  |  | Refugee Entry Date _____________
Hispanic (Hispano) |  |  |  | Single (Soltero/a) |  |  | Refugee Type:
Asian ([NAME]) |  |  |  | Married (Casado) |  |  | Refugee
Black/African American (Negro o [NAME]) |  |  |  | Separated (Separado) |  |  | [NAME]
Pacific Islander/Native Hawaiian (Nativo de Hawaii/Islas Pacifico) |  |  |  | Divorced (Divorciado/a) |  |  | Cubian or Haitian
Native American (Nativo Americano) |  |  |  | Widowed (Viudo/a) |  |  | Certain Amerasian
White (Blanco) |  |  |  | Single Mother ([NAME]) |  |  | [NAME]
 |  |  |  | Single Father ([NAME])
High School Graduate |  | Yes / No / GED |  | Country where you graduated |  |  | Last grade of school
[NAME]? |  |  |  | Pais donde se graduo |  |  | Último nivel de escuela
Are you a U.S. Citizen? |  | Yes  /  No |  | Native Country |  |  | How did you hear of our program?
Ciudadano de U.S.A.? |  |  |  | De done es? ([NAME] materna) |  |  | Cómo conoce de nuestro programa?
Do you have a medical condition we should be aware of?
Tiene una condicion médico que debemos conocer?
Yes  / No  Explain if Yes Explica
Short-Term Goal (select only one) |  |  |  |  | Long-Term Goal (select only one)
Meta Primordial de Corto Plazo (seleccione solamente una) |  |  |  |  | Meta Primordial de largo Plazo (seleccione solamente una)
Gain Employment / Obtener un empleo |  |  |  |  | Gain Employment / Obtener un empleo
Retain/Improve employment / [NAME] o mejorar en el empleo |  |  |  |  | Retain/Improve employment / [NAME] o mejorar en el empleo
Advance education level /  Avanzar a un mayor nivel educativo |  |  |  |  | Advance education level /  Avanzar a un mayor nivel educativo
Obtain diploma / Obtener un diploma |  |  |  |  | Obtain diploma / Obtener un diploma
Obtain GED /  Obetener un GED |  |  |  |  | Obtain GED /  Obetener un GED
Enter post secondary or job training /  Entrar al nivel post-secundario |  |  |  |  | Enter post secondary or job training /  Entrar al nivel post-secundario
Labor Force Status / Estatus Laboral |  |  |  |  | Disability Status |  |  | Rural Area Status
Not Defined / No definido |  |  |  |  | None |  |  | None
Employed / Empleado |  |  |  |  | Physically Impaired |  |  | Live in rural area
Umemployed /  Desempleado |  |  |  |  | Mentally Impaired |  |  | (population < 2500)
Not in Labor force /  No se encuentra |  |  |  |  | Specific Learning Disability
Literacy Program |  |  |  |  | Institutional Status |  |  | Public Assisstance Status
None |  |  |  |  | None |  |  | None
Homeless |  |  |  |  | In correctional facility |  |  | On public assistance
Family Literacy program (Even Start) |  |  |  |  | In community corrections  program
In workplace literacy program |  |  |  |  | In other institutional setting
OFFICE USE ONLY:                                     NIH                         Staff Initials |  |  |  |  |  | Testing Data:
SEOP & Registration |  |  | (45 min) | ___________Registrar |  | Pretest: |  | Posttest:
Signature on back of SEOP |  |  |  |  |  | Oral:  __________/_____ |  | Oral: ___________/_____
2 signatures on Sig. Page |  |  | (15 min)
Oral Test Complete or N/A |  |  | (30 min) | __________Test Adm |  | Wrtn: R____ W ____ T ____/ ____ |  | Wrtn: R____ W ____ T ____/ ____
Written Test Complete or N/A |  |  | (75 min) | __________Test Adm |  | ++++++++++++++++++++++++++++++++++++++++++++++++++++++
Registration Paid or N/A |  |  |  |  |  | Classes Registered for this Quarter:
Books distributed/ Class Place |  |  | (15 min) |  |  | ____M/W F  T/Th F S AM / PM |  | ____M/W F  T/Th F S AM / PM
Student written on Roll
Utah State Office of Education - Waiver Release:
I ______________________________ release all person data/SEOP information (to include social security
number) and GED scores, if applicable, to the Utah State Office of Education and other state agencies for client
counseling and data matching purposes, in addtion to any additional Adult Education program that I may
choose to attend.
Yo _____________________________ autorizo el uso de toda mi infomación personal de la data/SEOP
([NAME]) y las califaciones del GED si fuera aplicable,, a la Oficina Estatal de
Educación y a otras agecias estatales para propositos de consejos a clientes y comprobación de datos, además
de a cualquier Programa adicional de Educación de Adultos que you pudiera escoger asistir.
Student Signature (Firma del estudiante) |  |  |  |  | Date Signed ([NAME])
********************************************************************************************************************************
Teacher Comments:
Last Name |  |  |  | First Name |  |  | Birthdate (month/day/year)
Apellido |  |  |  | Nombre |  |  | [NAME] (mes/dia/año)
PLEASE READ BEFORE SIGNING:  Tuition is refunded |  |  |  |  | POR FAVOR [NAME]:  [NAME] matricula puede ser
through Friday of the first week of classes only. |  |  |  |  | rembolsada solo hasta el primer viernes [NAME].
I certify that the information I have provided on the registration |  |  |  |  | Certifico que la información que acabo de proveer es correcta y
form is complete and correct.  I am willing to provide income |  |  |  |  | completa.  Me comprometo a demonstrar prueba de recursos como
verification as required.  I give permission to release personal |  |  |  |  | sea requerido.  [NAME] permiso para compartir mi información personal
information including but not limited to : test scores, attendance, |  |  |  |  | que puede incluir pero no está limitado a: notas de exámenes,
training scores, SEOP's, and financial data to agencies or |  |  |  |  | [NAME], resultados de entrenamientos, SEOP's, y datos
employers.  I give permission for my photograph to be released |  |  |  |  | financieros a agencias y a fuentes de trabajo.  [NAME] permiso para que
for use by the (Program name Here) for purposes of |  |  |  |  | mi fotografia pueda ser utilizada por el (Program Name Here) con el
advertising or other reporting and presentation functions. |  |  |  |  | propósito de uso en propagandas y en otros reportes y presentaciones.
Date (Fecha) |  |  | Student Signature (Firma de estudiante)
We are very happy that you have come to the (Program |  |  |  |  | Estamous [NAME] venga al (Program Name Here).
Name Here) to attend your English class.  We promise we will |  |  |  |  | Nos comprometemos a proporcionarle de los mejores profesores y
do our best to provide you with an excellent teacher and good |  |  |  |  | materiales [NAME].
learning materials.
 |  |  |  |  | Es un gran oportunidad el tomar clases de inglés, las clases son
Taking an English course here is a wonderful opportunity for you. |  |  |  |  | gratuitas o a un costo bastante bajo ([NAME] clases [NAME]) y
Your class was free of charge except for your books (you pay |  |  |  |  | [NAME] for los libros.  El costo real de cada clase es de $360.00
only $25.00).  The acutal cost of your class should be $360.00. |  |  |  |  | dólares, pero usted ha recibido una beca [NAME].
You have received a scholarship to pay for your class.
 |  |  |  |  | Muchas personas desean atender nuestras clases [NAME], muchos
Many people want to attend our school.  Some people have to wait |  |  |  |  | tendrán que esperar hasta el próximo trimestre porque las clases
until next quarter because the classes are full.  For this reason, |  |  |  |  | [NAME]Por esta razón, es [NAME] que atienda su
it is very important that you attend your class regularly and continue |  |  |  |  | clase regularmente y continúe hasta el término del trimestre.
to come to class until the end of the quarter.  We understand that |  |  |  |  | Entendemos que vaya a estar ausente alguna vez por cuestiones
you might miss a class occassionally because of work, illness, |  |  |  |  | [NAME], enfermedad,o problemas familiares.  Por favor ha lo
or family problems. Pleas do your best to attend every class. |  |  |  |  | posible por atender cada clase.
I will do my best to attend every class  (Student Signature)
Hare lo posible por atender todas mis clases. ([NAME])
Our source of funding requires us to track household income.  This information wil be held strictly confidential.
Circle the household number size (number of people living in your home).  Then circle the  annual income category for your house hold size.
Household size |  | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8+
Income above this number |  | 29001 | 33151 | 37301 | 41451 | 44751 | 48101 | 51401 | 54701
Income below this number |  | 29000 | 33150 | 37300 | 41450 | 44750 | 48100 | 51400 | 54700
Income below this number |  | 18150 | 20700 | 23300 | 27950 | 30050 | 32100 | 32100 | 34200