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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
City
State
ZIP
Home Phone
Best Time to Call
Cell Phone
Type of program Preferred Independent Study OptionClassroom Option
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?
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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