BAKERSFIELD ADULT SCHOOL REGISTRATION FORM
Which course are you wanting to enroll in?
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Online Independent Study Course
In Person Instructor Led Course
Previously Enrolled at Bakersfield Adult School?
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Yes
No
Today's Date
Month
Please Select
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Day
Please Select
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Year (YYYY)
Sexual Orientation
*
MALE
FEMALE
NON-BINARY
Name
*
FIRST NAME
MIDDLE NAME
LAST NAME
OTHER NAME USED AT BAS
*
Address
*
STREET ADDRESS
Street Address Line 2
CITY
State / Province
ZIP CODE
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
COUNTRY OF BIRTH
CELL PHONE #
*
Please enter a valid phone number.
DATE OF BIRTH (MM-DD-YY
*
-
Month
-
Day
Year
Date
NATIVE LANGUAGE
*
E-MAIL ADDRESS
*
example@example.com
EMERGENCY CONTACT NAME
*
TELEPHONE
*
MEDICAL ISSUES
*
ETHNICITY
*
Hispanic/Latino
Not Hispanic/Latino
Decline to State
ETHNICITY
*
Native American
Other Asian
Chinese
Hawaiian
Japanese
Guamanian
Korean
Samoan
Vietnamese
Tahitian
Asian Indian
White
Laotian
Filipino
Cambodian
African-American
Hmong
Other
MARITAL STATUS:
*
Married
Single
NUMBER OF DEPENDENTS
*
ARE YOU THE PARENT/GUARDIAN OF A KHSD STUDENT?
*
Yes
No
If yes, what School(s):
ARE YOU THE PARENT/GUARDIAN OF AN ELEMENTARY OR MIDDLE SCHOOL STUDENT?
*
Yes
No
If yes, what School(s):
EMPLOYMENT STATUS:
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Employed
Unemployed
HIGHEST YEAR OF SCHOOL COMPLETED (Check your answer):
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1
2
3
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5
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9
10
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18
19
The majority of my schooling was out of the U.S.:
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Yes
No
HIGHEST DIPLOMA OR DEGREE EARNED (mark one):
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None
High School Diploma
High School Equivalency GED, HiSet, etc
Technical Certificate
Some college, no degree
A.A. or A.S Degree
4-Year College Graduate
Higher than a B.A./B.S. Degree
PLEASE MARK ALL THAT APPLY TO YOU:
This information is collected for data collection purposes only.
Do you have a physical disability?
*
Yes
No
Do you have a documented learning Disability (I.E.P., 504 Plan, etc.)?
*
Yes
No
Are you a displaced homemaker?
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Yes
No
Was English your first language?
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Yes
No
Have you ever been convicted of a crime?
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Yes
No
Are you temporarily living with a relative or friend?
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Yes
No
Have you been looking for work for 7 months or longer?
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Yes
No
Are you a Migrant farmworker?
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Yes
No
Are you a seasonal farmworker?
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Yes
No
Are you a single parent? (not legally married)
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Yes
No
Are you receiving unemployment benefits?
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Yes
No
Are you receiving cash aid (TANF)?
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Yes
No
Are you receiving food stamps, EBT, SNAP or CalFresh?
*
Yes
No
Are you a veteran?
*
Yes
No
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