2020-2021 Adult Education Registration
The Information below is used to comply with State and Federal funding requirements. All information will remain confidential.

You will be contacted by our Adult Education Office to confirm your registration and set up a date for orientation and CASAS** testing if needed.

**As a Title II Funded Agency, all Benicia Adult school ESL, GED, HSD, and Math students are required to participate in CASAS testing throughout the year.
Email address *
First Name *
Middle Name
Last Name *
Date of Birth (Must be over 18+ years old) *
MM
/
DD
/
YYYY
Gender *
Address Line #1 *
City *
Zip Code *
Cell Number or Land Line # *
Email
Ethnicity/Race *
Required
Country of Origin: In which country were you born?
Native Language *
Barriers to Employment (Mark ALL that apply) *
Required
Status/Public Assistance (Mark ALL that apply) *
Required
Special Programs (Mark ALL that apply) *
Income Level (optional) (maximum annual household income including public assistance) *
Labor Force Status *
My goals for this program year are to: (Choose at least two goals) *
Required
Instructional Program *
Next
Never submit passwords through Google Forms.
This form was created inside of Benicia Unified School District. Report Abuse