Duluth Adult Education - DAE - Computer Skills Referral Form (Conditional Work Referral for Adult Basic Education Workforce Preparation Services)
Thank you for your interest in working with us.  Submitting this form refers your client to the DAE Conditional Work Referral program to work on computer skills development. 

Your client must meet the following criteria:
> Be at least 17 years old
> Not be enrolled in public K-12 school
> Not have goals to improve reading, writing, math skills
> Be receiving services from an employment services provider before being referred 
> Complete the form below

After submitting this form, your client may attend our Study Session Drop In to work with a teacher.
Tues., Wed., Thur. from 1:30-3:30.

Thank you!
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A. Name of Referring Agency:
B. Referred by (staff contact name):
C. Staff contact phone and email:
D. Referring program (MFIP, Youth Program, Dislocated Worker, Vocational Rehab, Employment Service, P2P, etc.)
Clear selection
E. I understand I am making a referral for digital literacy skill development
Clear selection
F. Please notify the referring agency once the client is receiving ABE services:
Clear selection
G. Please provide progress reports (if requested, these will be given to the client):
Clear selection
H. Please describe the current digital literacy level and the skills you client would like to develop:
The questions below are collecting information about the CLIENT you are referring:
Client First Name *
Client Last Name *
Client Middle Name *
Nick Name/Preferred Name
Preferred pronouns (she/her, he/him, they/them, etc.)
Email *
Primary Phone *
Street Address *
City, State, Zip                                                         County *
Date of Birth *
MM
/
DD
/
YYYY
Gender: *
Hispanic/Latino *
Race (Choose only one) *
Work Status  (Choose only one) *
Do you receive public assistance? (Choose only one) *
Highest Formal Education (Choose only one) *
Education Location *
Social Security Number: Providing your SSN helps us meet state and federal reporting requirements.  We do not share your SSN with anyone.
Tennessen Warning: We need to ask you for the following information for our program records: name, birth date, gender, race/ethnic group, employment status. We may share some information with teachers and other staff of Duluth Public Schools. We report this information to the MN Department of Education for annual reporting and funding. We will only share this information with other organizations if you give us permission. Thank you. I have read this: *
Thank you for completing this form. Once you click submit below, your client may attend our Study Session Drop In times 1:30-3:30 on Mon, Tues, Wed, and Thur at DAE Downtown: 325 W. 1st St. 3rd Floor. When they arrive, please tell them to let our front office person know that they were referred for computer skills from your agency.
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