East Side Adult Education ESL/Citizenship Registration Form - Fall 2020
ESL/ELL Please take time to complete the information below.
Email address *
Student Registration *
Required
I would like to enroll in ONE of the following session & location *
SCHOOL Student ID# (9 numbers)
Name: First & Middle *
Name: Last *
Address: Street *
City *
State: CA
Zip Code *
Primary Contact Number *
Is this a cell phone? *
Secondary Contact Number
Emergency Contact: Name *
Emergency Contact: Relationship *
Emergency Contact: Phone Number *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Are you Hispanic or Latino? *
Race (check all that apply) *
Required
Native Language (check one) *
Highest Year of Schooling Completed (check one) Note: High School completion equals to completion of 12th Grade in the U.S. Please mark correctly. *
Majority of my school was outside of the U.S *
Required
Highest Degree Earned ( check one) *
Earned above outside of U.S *
Please continue to complete more information. My attainable goals within the program year. Please select two. *
Required
Special Programs. (Mark all that apply) *
Required
Employment Status *
Employment Barriers (Mark all that apply) *
Required
Registration Completion Date *
MM
/
DD
/
YYYY
Thank you for completing our online registration form. To be officially registered in a class, please come to one of our office locations to determine your English proficiency and to be placed in the program or put on the waiting list. Please click submit below.
A copy of your responses will be emailed to the address you provided.
Submit
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