Farmworker Pre-Intake form

1.	Name:*

2.	Phone:* (000)000-0000

3.	Address:*

4.	City:*

5.	State:*

6.	Email:

7.	Contact method preferred:*
	Phone    Email    Text

8.	Do you have a GED or HS Diploma?*
	Do you have a GED or HS Diploma?* Yes No

9.	Are you currently attending classes?*
	Are you currently attending classes?* Yes No

10.	Have you or a parent worked in farm work during the past 24 months?*
	Have you or a parent worked in farm work during the past 24 months?* Yes No

	The Florida Department of Education Farmworker Career Development Program (FCDP) is funded through the Workforce Innovation and Opportunity Act, Section 167, by the United States Department of Labor, Employment and Training Administration.