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Program Requested
High School DiplomaG.E.D.ESL (English as a Second Language)U.S. CitizenshipBasic Skills

First Name

Last Name

Middle Name

Email Address

Physical Address

City

State

ZIP

Mailing Address if Different

City

State

ZIP

Home Phone

Best Time to Call

Cell Phone

Best Time to Call

Type of program Preferred
Independent Study OptionClassroom Option

School/Employment History

Highest School Grade Achieved
K123456789101112

High School

Years of High School Completed

High School Graduation Date

College/University/Vocational School

Years of College Completed

College Graduation Date

Field of Study

Degree
N/AA.A.B.A./B.S.Ph.D.

Employment Status
Employed Full-timeEmployed Part-TimeSelf-EmployedUnemployedHomemakerRetiredDisabledActive Military DutyStudent Full-TimeStudent Part-TimeOther

Current Employer

Occupation

Employer Phone Number

Employed Since

Is this a Seasonal Occupation? If so, when does the season run?

Background History

Date of Birth

MaleFemale

Birth State

Birth Country

Marital Status
SingleMarriedWidowedDivorced

Preferred Language

Last Year you attended a school?

Veteran?
Air ForceMarinesArmyNavy

Years Served

Homeownership Status?

Ages of children?
<1123456789101112131415161718>18

How are you parenting?
With a partnerOn your ownWith a family member (parent, grandparent)

Would you need your kids watched?
YesNo

If so, what are the ages of the children?

Are you currently a CalWORKs Client?
YesNo

If you are currently being served by CalWORKs, they will be notified of your enrollment.

Are you in another workforce reentry program?
YesNo

ETHNICITY: Mark the ethnicity with which you most closely identify: Please check one:

Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)Not Hispanic or Latino

WHAT IS YOUR RACE (Please check up to five racial categories) the above part of the question is about ethnicity, not race. No matter what you selected above, please continue to answer the following by marking one or more boxes to indicate what you consider your race to be.

American Indian or Alaskan Native (Person having origins in any of the original people of North and South America (including Central America))ChineseJapaneseKoreanVietnameseAsian IndianLaotianCambodianHmongOther AsianHawaiianGuamanianSamoanTahitianOther Pacific IslanderFilipinoWhite (Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East)African American or Black

I/We give permission for my/our student to be observed, interviewed, photographed and/or filmed when a representative of the media have been permitted by the principal or designee to be on campus.
YesNo

By submitting this form, I verify that the information on this Student Enrollment Form is true to the best of my knowledge, and I understand that any incorrect information could compromise the enrollment.

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