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<br /> 'Sent By: HawCC OCET; 9747487; Oct-18-02 12:44PM; Page S/6 <br /> Rural Development Project Standard Intake Form , <br /> This program Is made possible through funds provided try the Rural Development Project (RDP.) The <br /> RDP originates from the pepartmeM of Labor and us made posslDle through a grant awarded to the <br /> Unlvetslry of Hawaii system for distribution to the Communlry Colleges and Educational Centers on five <br /> islands (Hawel'I, Maul, MOloke'I, Lene'I, erW ICaue'I). <br /> In order to best serve the community of Ffavraii with oontlnuing Drograma, the RDP requests that ell <br /> parttdpents proNde us with the folbwing information. This information will De used soley for the <br /> purposes of evaluating the populatlon served and the effectiveness of the sponsored program. The <br /> asterisks mark all required Information. <br /> Name 8 Addreea <br /> First• Last" <br /> AddreaB• <br /> City Staue• Zip• <br /> Nome or Confect Phone• SSN <br /> Date of Bhrth` Gender: Male Female <br /> (Mo/Day/Yr) <br /> Ethnicity Country of Citizenship <br /> Family Status ~ Family Size (including self) <br /> (select one from the list below) <br /> Parent in 1 parent home <br /> Parent In Z parent home Dependents under 18 <br /> Other family member <br /> - No[ a family member <br /> Status (sclect one from the list below)• <br /> _ Student, High School or less <br /> _ Student attending College or T2de School <br /> Number of Credit Hours <br /> _ MS Drop Out without GED <br /> _ HS Drop Out with GF~ <br /> _ HS Grad with employment dlfFlcultles <br /> HS Grad without employment dtfflculUes <br /> Last Grade Completed' Basic Litcrscy Skills (Y/N)• <br /> <br />