Ukiah Adult School Registration Form (for all programs except Vocational Nursing)

Student Information

Please complete the form below for all programs except Vocational Nursing

Required fields are marked with an asterisk *

Please fill out a current High School transcript request form.

Contact Information

First Name*

Answer required for "First Name"

Middle Initial

Answer required for "Middle Initial"

Last Name*

Answer required for "Last Name"

Phone Number*

Number Required

Address

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Ok to send text?

Answer required for "Ok to send text?"

Yes

Email address

Answer required for "Email address"

Gender*

Answer required for "Gender"

Male

Female

Non Binary

Date of Birth*

Answer required for "Date of Birth"

Social Security # or ITIN # (Optional):

Answer required for "Social Security # or ITIN # (Optional):"

No SS #? Check here

Answer required for "No SS #? Check here"

No SS

Race (Please check all that apply):*

Answer required for "Race (Please check all that apply):"

Alaska Native

American Indian

Asian

Black / African American

Native Hawaiian

Pacific Islander

White

Hispanic or Latino (select one):

Answer required for "Hispanic or Latino (select one):"

Yes

Native Language:

Answer required for "Native Language: "

Employment Status*

Answer required for "Employment Status"

Employed

Unemployed, looking for work

Not looking for work

Unavailable/unable to work

Retired

Full time student

Education History: *

I am attending school now:

Answer required for "Education History: "

Yes

Was the majority of your education earned outside of the United States?

Answer required for "Was the majority of your education earned outside of the United States?"

Yes

I am interested in the following programs (please check all that apply):

Answer required for "I am interested in the following programs (please check all that apply): "

Citizenship

Finishing High School

GED Prep

Improving English Language Skills (ESL)

Other:

Emergency Contact (Name, Relationship, Phone #)

Name

Answer required for "Name"

Relationship

Answer required for "Relationship"

Phone Number

Answer required for "Phone Number"

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”).

Name*

Answer required for "Name"

Date*

Answer required for "Date"

I request the California Employment Development Department to supply my ongoing current and historical employment information to be shared between the agencies to facilitate the services to which I may be referred.

(initials below please)

Answer required for "I request the California Employment Development Department to supply my ongoing current and historical employment information to be shared between the agencies to facilitate the services to which I may be referred. "

(optional) I agree to allow my social security number or tax identification number to be shared between the agencies to facilitate the services to which I may be referred.

(initials below please)

Answer required for "(optional) I agree to allow my social security number or tax identification number to be shared between the agencies to facilitate the services to which I may be referred. "

(optional) I authorize MENDOCINO LAKE ADULT AND CAREER EDUCATION (ML ACE) members to use my likeness for promotional materials associated with ML ACE programs or services.

(initials below please)

Answer required for "(optional) I authorize MENDOCINO LAKE ADULT AND CAREER EDUCATION (ML ACE) members to use my likeness for promotional materials associated with ML ACE programs or services."

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

Please fix the highlighted areas below before submitting.

Ukiah Adult School Registration Form (for all programs except Vocational Nursing)