AV Adult School: New Student Registration Form 
Please complete this form if this is your first time taking a class at Anderson Valley Adult School.
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Class selection. Please write the names of all classes for which you would like to register. (You can view available offerings on our website.) *
First & Last Name *
Gender: *
Required
Date of birth: *
Residential address: *
Mailing address: *
Phone number (home or cell) *
Emergency contact (name, relationship, phone) *
Student type (please select all that apply) *
Required
Student income / benefits (please select all that apply) *
Required
Race (please select all that apply) *
Required
Hispanic or Latino *
Required
native language
Employment status: *
Required
Education history (highest year of school completed / and was the majority of it completed in the U.S.?) *
Highest degree / diploma earned *
Required
Approximate annual household income:
Total number of adults and dependents supported by the income above:
My goals are: *
Required
Signature (By typing your name below, you are verifying that the information above is true and correct.) *
When everything has been completed please make sure to hit the 'submit' option below
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