Center for New Directions Application

Idaho Career & Technical Education is required to collect data from recipients of Federal Perkins funds as a requirement of the Strengthening Career and Technical Education for the 21st Century Act (known as Perkins V). This includes disaggregated data by CTE programs, gender, race, and special populations.

*First name
*Last name
*Address line 1
Address line 2
*City
*State
*Zip
*Phone	Can we leave a voicemail at this number? YesNo Can we text you at this number? YesNo

*Email	*Can we email you? YesNo

Program of study NIC students only
Student ID NIC students only
*Gender	*Gender Female Male Not listed Prefer not to answer Other, if not listed

*Date of birth
*Ethnic origin	Ethnic origin African American Asian/Pacific Islander Caucasian Hispanic Native American Other
*Is English your first language?	Is English your first language? Yes No
Disability	Disability Yes No Examples include hearing impaired, deaf, speech impaired, visually impaired, mental health disorders, orthopedic impairment, handicapped, learning disability, etc. If yes, please explain

Dependent status	Dependent status I am a single parent A single parent with primary financial and custodial responsibility for supporting dependent children and who must gain employment skills in order to earn a living. I have legal guardianship/custody of my child.

*Number of children
Ages of children
*Are you a Displaced Homemaker?	Are you a Displaced Homemaker? Yes No Have you worked in the home providing household services for family members, but lost the primary source of economic support and must gain employment skills in order to earn a living?

*Marital status	Marital status I am married and spouse is employed or retired w/income I am married and spouse is unemployed/retired with NO income I am married spouse is disabled. I am married, but I am not living with spouse I am legally separated I am divorced I am widowed I have never been married

*Source of current HOUSEHOLD income	Source of current HOUSEHOLD income Alimony Child support Food stamps Medicaid/Medicare Salary Social Security/Retirement SSI Unemployment Welfare/TAFI Other public assistance Other

*Financial status	Annual HOUSEHOLD income from all current sources Less than $5,000 $5,001 to $10,000 $10,001 to $15,000 $15,001 to $20,000 $20,000 to $25,000 $25,001 +

*Educational history	Educational history 11th grade or less High school graduate GED graduate Some college (academic) Some college (vocational/trades & industry) Associate's degree Bachelor's degree Master's or beyond

*Current or most recent job
*Areas of interest	Areas of interest Trades & Industry Health Professions/Nursing Business & Professional Programs Hospitality Aerospace Other

*Digital signature