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

Middle Initial

Answer Required

Last Name*

Answer Required

Phone Number*

Number Required

Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Ok to send text?

Answer Required

Yes

Email address

Answer Required

Gender*

Answer Required

Male

Female

Non Binary

Date of Birth*

Answer Required

Social Security # or ITIN # (Optional):

Answer Required

No SS #? Check here

Answer Required

No SS

Race (Please check all that apply):*

Answer Required

Alaska Native

American Indian

Asian

Black / African American

Native Hawaiian

Pacific Islander

White

Hispanic or Latino (select one):

Answer Required

Yes

Native Language:

Answer Required

Employment Status*

Answer Required

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

Yes

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

Answer Required

Yes

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

Answer Required

Citizenship

Finishing High School

GED Prep

Improving English Language Skills (ESL)

Other:

Emergency Contact (Name, Relationship, Phone #)

Name

Answer Required

Relationship

Answer Required

Phone Number

Answer Required

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

Date*

Answer Required

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

(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

(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

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)