Yes No Race: (Check One) Single Pregnant Woman: (Check One) 0 - Native American 1 - African American Disabilities: (Check One) 2 - Hispanic 3 - Caucasian 4 - Asian 0 Not disabled 1 Mental retardation – – Gender: (Check one) Male Female 2 Hearing impaired, including deafness – 4 Speech or language impaired – Marital Status: (Check One) 5 Visually impaired, including blindness – S Single M Married D Divorced – – – 6 Seriously emotionally disturbed – P Separated L Legally Separated W - Widowed – – 7 Orthopedically impaired 8 Other health impairment – – Names and ages of your children: 9 Specific learning disability B Autism C Head injuries – – – Name Age & last) Adult Offender: (Check One) Yes No Name (First & last) Age Juvenile Offender: One) Yes No Name & last) Age Secondary Education: One) Name (First & last) Age 1 Received high school diploma 2 Received GED – – Name (First Age & last) 3 Did not receive high school diploma or GED – Name (First & last) Age Number of Other Dependents ___ Post Secondary Education: (Check One) 1 None 2 Some 3 Associate – – – Limited English: (Check One) Yes No 4 Baccalaureate 5 Masters 6 Doctoral – – – Single Parent: One) Yes No
Race: (Check One) 0 - Native American 1 - African American 2 - Hispanic 3 - Caucasian 4 - Asian Gender: (Check one) Male Female Marital Status: (Check One) S – Single M – Married D – Divorced P – Separated L – Legally Separated W - Widowed Names and ages of your children: Name & last) Age Name (First & last) Age Name & last) Age Name (First & last) Age Name (First & last) Age Name (First & last) Age Number of Other Dependents ___ Limited English: (Check One) Yes No Single Parent: One) Yes No Single Pregnant Woman: (Check One) Yes No Disabilities: (Check One) 0 – Not disabled 1 – Mental retardation 2 – Hearing impaired, including deafness 4 – Speech or language impaired 5 – Visually impaired, including blindness 6 – Seriously emotionally disturbed 7 – Orthopedically impaired 8 – Other health impairment 9 – Specific learning disability B – Autism C – Head injuries Adult Offender: (Check One) Yes No Juvenile Offender: One) Yes No Secondary Education: One) 1 – Received high school diploma 2 – Received GED 3 – Did not receive high school diploma or GED Post Secondary Education: (Check One) 1 – None 2 – Some 3 – Associate 4 – Baccalaureate 5 – Masters 6 – Doctoral
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