Adult Program Application

Which program(s) are you interested in?*

Adult High SchoolEnglish as a Second LanguageHigh School Diploma Program (ages 16-24)GED Testing

Which ESL course(s) are you interested in?*

ESL IESL IIESL III

First Name*

Middle Name

Last Name*

Address*

Example: 123 Main Street Apt 1

City*

State*

Zip Code*

Email*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Gender*

Date of Birth*

Date

Age*

Are you able to provide a Social Security Number?*

Social Security Number*

Home Language*

Country of Birth*

State of Birth*

City of Birth*

Are you Hispanic or Latino?*

YesNo

Race*

Alaska Native - A person having origins in any of the original people of indigenous tribes and villages of Alaska, for example:

Aleuts, Northern Eskimos (Inupiat), Southern Eskimos (Yuit), Interior Indians (Athabascans) and Southeast Coastal Indians (Tlingit and Haida)

American Indian - A person having origins in any of the original people of North and South America (including Central America) and who maintains a tribal affiliation or community attachment, for example:

Chorotega, Miskito, Guaymí, and Kuna
Cherokee, Apache, Blackfeet, Navajo, Sioux, Chippewa, Assiniboine, Cree, Crow, Inuit, Seminole
Aztec, Maya, Taino, Maya Central American, Mexican Indian

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example:

Cambodia
China
India
Japan
Korea
Malaysia
Pakistan
the Philippine Islands
Thailand
Vietnam

Black or African American - A person having origins in any of the black racial groups of Africa.

Native Hawaiian - A person having origins in any of the original peoples of Hawaii.

Other Pacific Islander - A person having origins in any of the original peoples of Guam, Samoa, or other Pacific Islands.

White - A person having origins of the original peoples of Europe, the Middle East or North Africa.

Emergency Contact's Name*

First NameLast Name

Address*

Example: 123 Main Street Apt 1

City*

State*

Zip Code*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email

Highest Grade Attended*

Last High School Attended*

Did you have a G.E.D. diploma?*

YesNo

Have you ever attended this school before?*

YesNo

What year?*

Do you have a certificate from a Vocational School?*

YesNo

Signature*

Date*

Date

Please upload a Photo ID*

Proof of Address*

High School Transcript*

Social Security Card*

Adult Program Application

Section 1: Student Information

Section 2: Demographics

Hispanic or Latino

Race

Section 3: Emergency Contact

Section 4: Student Education Record

Section 5: Electronic Signature

Documentation(s) Required