Intake Form - Ada S. McKinley

EDUCATIONAL SERVICES STUDENT IN-TAKE

Ada S McKinley Back to School Festival 082219

Welcome to the online front door of our Educational Services Program.

Please complete the following In-Take and Collaboration Consent forms to confirm your interest in receiving our services and determine your eligibility. If you have any questions, please email our Educational Services Team at [email protected]

You will need to upload the following documents when completing this form:

Unofficial High School Transcript

Parent’s 1040 Tax form for 2020 (or most recent year available), a SSI Statement, or a Medical Card.

Current ACT or SAT scores

If you have already completed this form and only need to submit specific documents requested by our team, please email them to [email protected]

STUDENT INFORMATION
Full Name of Student (As it should appear on official documents. Please capitalize where necessary.)*
First Middle Last
Social Security or CPS ID #
Telephone #*
Email Address*
Address*
Street Address Address Line 2 City State ZIP Code
Gender*
- Male
- Female
Birth Date*
MM slash DD slash YYYY
Current Age*
Race*
- African American
- American Indian
- Latino
- Asian
- Caucasian
Citizen of U.S*
- YES
- NO
Are you a Veteran?*
- YES
- NO
If you are not a citizen, are you a permanent resident?*
- YES
- NO
Enter Permanent Resident Alien Number
FAMILY BACKGROUND
Family Background*
- One parent family
- Live with legal guardian
- Ward of State (documentation attached)
- Live with both parents
- Live alone
- Homeless (documentation attached)
Older Brothers/Sisters*
- YES
- NO
Has any of your siblings attended college?*
- YES
- NO
Highest degree earned by a sibling*
- Associates
- Bachelor's
- Masters's
- Doctoral
FAMILY SIZE
Number of family members in household, including yourself*
PARENT INFORMATION
Mother's Education Level*
- Below 9th Grade
- H.S. Dropout
- H.S. Graduate
- Some College
- 4 year BA Degree
- Post College
Father's Education Level*
- Below 9th Grade
- H.S. Dropout
- H.S. Graduate
- Some College
- 4 year BA Degree
- Post College
Occupation of Mother - This is a required field. If unemployed, please indicate by typing in Unemployed.*
Occupation of Father - This is a required field. If unemployed, please indicate by typing in Unemployed.*
My family taxable (not total) income from the last calendar year was?
*NOTE: Your taxable income can be found on the federal income tax return you filed for the last calendar year (on IRS Form 1040) see line 43; (on IRS Form 1040A), see line 27; (on IRS Form 1040EZ) see line 6; or (on IRS Telefile) see line K1)
Family Income attest
- I attest that my family did not file a federal tax return for the last calendar year.
- I attest that my family had no taxable income for the last calendar year.
- I attest that the information submitted to complete FAFSA is accurate.
My family’s income was
STUDENT INFORMATION
Grade Level*
Name of Current School*
If High School, indicate Seminar instructor/room
High School Cumulative GPA (Weighted)
High School Cumulative GPA (Un-weighted)
College Entrance Exams
- PARCC/NWEA
- PSAT
- SAT
- ACT
PARCC/NWEA Reading
PARCC/NWEA Math
PSAT Verbal
PSAT Math
SAT Verbal
SAT Math
SAT Computer
ACT English
ACT Math
ACT Science
ACT Reading
ACT Composite
If not enrolled in high school, please check one of the following:
- High School Dropout
- High School Graduate
- GED Enrolled
- GED Graduate
- College Enrolled
- College Graduate
- College Dropout
Year Graduated
Reason
Complete this section only if you are a college graduate or college enrolled
Name of College
Major
Semester Hours
Quarter Hours
GPA
Degree
PLEASE ATTACH THE FOLLOWING DOCUMENTS (REQUIRED)
(If you need more time to retrieve these documents, you can skip the attachments. Please email them in the near future to our Educational Services team at [email protected] Your intake process will not be complete until these documents are received.)
Unofficial High School Transcript
Max. file size: 50 MB.
Parent's 1040 Tax form for 2020 (or most recent year available), a SSI Statement, or a Medical Card.
Max. file size: 50 MB.
Current ACT or SAT scores
Max. file size: 50 MB.
Read, sign, and date
By signing this application, I attest that all information on this application is true:
By signing this application, I attest that all information on this application is true:
Student Signature

(If student is over the age of 18. If student is over the age of 18 but has a legal guardian appointed by the court, the legal guardian must sign)
Date
MM slash DD slash YYYY
Parent or Legal Guardian Signature

(If under the age of 18, a parent or a legal guardian appointed by the court must sign).
Date
MM slash DD slash YYYY
COLLABORATION CONSENT FORM

Ada S. McKinley Community Services, Inc.

Purpose: This form is to be used to obtain permission to exchange information with other agencies also providing services to the client. The purpose of this form is to obtain consent for Ada S. McKinley Community Services, Inc. (Agency) to coordinate service planning and delivery with representatives of established referral agencies. The representatives of these agencies may participate in scheduled meetings and record reviews and may obtain copies of information specific to case coordination. This form is also being used to obtain permission to use to use, publish, republish and/or disclose with or without identification any and all photographs, videos, films, drawings and other likenesses still or moving, taken or made and statements referring to and in conjunction with desires.

In order to coordinate service planning and delivery, the Agency expects to exchange information established agencies. This release authorizes a free exchange of information including, but not limited to, participation in scheduled meetings, review of records, or exchange of copied information for the purpose of securing services in order to meet the programming needs and to assist in achieving goals and improving skill level.

This information is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), governing the privacy of client health information, (including the HIPAA Privacy Rule), The Mental Health and Developmental Disabilities Confidentially Act, Americans with Disabilities Act, The Nursing Home Care Act, and other federal and Illinois statutes and regulations. Representatives of the agency, identified above, are required to adhere to confidentiality laws identified in this document. Furthermore, the agency named above may not disclose this information legally to another party without written consent.

I hereby give consent and permission to Ada S. McKinley Community Services, Inc. and its representatives to use, publish, republish and/or disclose with or without identification any and all photographs, videos, films, drawings and other likenesses still or moving, taken or made and statements referring to and in conjunction with desires. I further authorize the Agency and its representatives to use, publish, disclose or disseminate statements with promotions.

This consent to disclose photographs and statements is valid for a period of 12 months, but the consent to republish or re-disclose shall continue to be valid after 12 month period until such time as I revoke my consent.

I further waive, release, discharge and disclaim any rights or claims to payment or compensation for this release or the use of likeness, and waive, release, discharge and disclaim any damages or injuries which may occur as a result of this consent.

I understand that I have a right to inspect and to obtain a copy of any photographs taken by the Agency, its employees or agents. I may arrange for inspection and/or copy by contacting the Agency. The Agency will provide me with one (1) copy of each photograph free of charge at my request.

I understand that I may revoke this consent at any time by contacting the Agency, and that I will suffer no consequences of any type from the Agency.

By signing this agreement, I give Ada S. McKinley Community Services, Inc. permission to share information on my behalf with established agencies, and to use to use, publish, republish and/or disclose with or without identification any and all photographs, videos, films, drawings and other likenesses still or moving, taken or made and statements referring to and in conjunction with desires. Unless revoked in writing, this agreement and exchange shall remain in force for a period of 12 months from the date of authorization.

I understand that I have the right to revoke this agreement and may do so in writing at any time. If I do not sign this form or revoke the authorization, information will not be shared and I will have to contact each agency individually to give information whenever it is needed.
Student Full Name
Student Signature

(If student is over the age of 18. If student is over the age of 18 but has a legal guardian appointed by the court, the legal guardian must sign)
Date
MM slash DD slash YYYY
Parent or Legal Guardian Signature

(If under the age of 18, a parent or a legal guardian appointed by the court must sign).
Date
MM slash DD slash YYYY

EDUCATIONAL SERVICES STUDENT IN-TAKE

STUDENT INFORMATION

FAMILY BACKGROUND

FAMILY SIZE

PARENT INFORMATION

STUDENT INFORMATION

Complete this section only if you are a college graduate or college enrolled

PLEASE ATTACH THE FOLLOWING DOCUMENTS (REQUIRED)

Read, sign, and date

COLLABORATION CONSENT FORM

Ada S. McKinley Community Services, Inc.