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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




    Mailing Address if Different




    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

    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


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

    Current Employer


    Employer Phone Number

    Employed Since

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

    Background History

    Date of Birth


    Birth State

    Birth Country

    Marital Status

    Preferred Language

    Last Year you attended a school?

    Air ForceMarinesArmyNavy

    Years Served

    Homeownership Status?

    Ages of children?

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

    Would you need your kids watched?

    If so, what are the ages of the children?

    Are you currently a CalWORKs Client?

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

    Are you in another workforce reentry program?

    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.

    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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