Ukiah Adult SchoolUkiah Unified School District

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Ukiah Adult School Registration Form

Student Information

Please complete the form below.

Required fields are marked with an asterisk *

Contact Information
No SS #? Check here
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Gender*
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Address
State*
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Ok to send text?
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Emergency Contact (Name, Relationship, Phone #)

Race (Please check all that apply):*
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Hispanic or Latino (select one):
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Employment Status*
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Education History: *
I am attending school now:
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Highest grade/level completed:
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Was the majority of your education earned outside of the United States?
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I am interested in the following programs (please check all that apply):
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Acknowledgment and Signature

By my signature below, I verify that all information contained in this document is true and correct. I also authorize the release of my education, training, employment, and other related information to the Mendocino Lake Adult and Career Education member agencies and their sub-grantees, sub-contractors, service provider partners, or a designated representative thereof to facilitate the services to which I may be referred. I understand that I will only be referred to a member agency at my request. All agencies and related partners and their staff are bound by contract and by law to maintain your confidential information according to the standards set forth by the Federal Education Rights and Privacy Act (“FERPA”), by the California Education Code section 49073.1 and, as appropriate, by the Health Information Privacy Protection Act (“HIPAA”).

This consent may be cancelled at any time. Subject to cancellation this consent for data sharing will remain in effect for three years.

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