Placement Form





Date which you would like to attend Placement Session:

How did you hear about VIDA:
Select OneNewspaperRadioWebsiteSocial MediaVIDA StudentVIDA StaffCollege ProfessorCollege StaffWorkForceOther

First Name:

Last Name:

Date of Birth:

Last four digits of your Social Security Number:

Address:

Address Line2:

City:

State:

Zipcode:

Email Address:

Phone Number:

Age:

Gender:
MaleFemale

Citizenship:

Immigrant:
YesNo

Migrant Worker:
Select OneYesNo

Educational Attainment:

Have you passed at least two sections of the Accuplacer, Thea or the TSI?
YesNo

If Yes please provide scores on each area:
Reading:

Writing:

Math:

Are you currently enrolled in College/University?
YesNo

If Yes, what institution?

Program of Study (Major):

Total Credit Hours Earned:

Current GPA (MUST BE 2.0 or GREATER TO BE CONSIDERED:

Have you served in the Armed Forces?

Date of Discharge:

Are you a Spouse or Dependent of a Vet?:
YesNo

Have you ever been convicted of a felony or a misdemeanor?
YesNo

Marital Status:

Single Parent?
YesNo

Number of children?

Number of children living with you?

Household Languages?

Eligibility?
UnemployedPublic AssistanceLow IncomeUnderemployed (earning less than $8.50 per hour)