SY26-27 Milpitas Adult Education ESL/Citizenship Registration

1
Name* This field is required.
First Name
Last Name
2
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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
3
Phone Number* This field is required.
(###) ###-####
4
Email* This field is required.
example@example.com
5
Gender* This field is required.
Female
Male
Prefer not to say
6
Date of Birth* This field is required.
Date
Month
Day
Year
7
SMS Communication: I agree to receive text messages from Milpitas Adult Education for reminders and communications related to school and classes.* This field is required.
YESNO
8
Milpitas Adult Education Student ID:(all students may not have a student ID)
9
Race (Check all that apply)* This field is required.
White
Asian
Alaska Native
Hawaiian Pacific Islander
Black/African American
American Indian
Filipino
Middle Eastern/North African
Other
10
Are you Hispanic/Latino?* This field is required.
YESNO
11
Native Language* This field is required.
American Sign Language
Amharic
Arabic
Armenian
Assyrian
Bengali
Burmese
Cambodian
Cantonese
Chinese
Croatian
Dutch
English
Farsi
French
German
Greek
Gujarati
Haitian
Hebrew
Hindi
Hmong
Hungarian
Ilocano
Indonesian
Italian
Japanese
Karen
Korean
Kurdish
Lao
Mandarin
Mongolian
Navajo
Nepali
Pashto
Polish
Portuguese
Punjabi
Romanian
Russian
Samoan
Serbian
Somali
Spanish
Tagalog
Thai
Tongan
Turkish
Ukrainian
Urdu
Vietnamese
Other
12
Employment Status (check one)* This field is required.
Employed
Employed with Notice (laid-off)
Unemployed
Not in the labor force (e.g. retired, full-time student, homemaker)
13
Highest Year of Schooling Completed* This field is required.Please select one.
Please select one
Please select one
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20+
14
Majority of my schooling was outside the United States* This field is required.
YESNO
15
Highest Degree Earned* This field is required.
None
HSE Certificate
High School Diploma
Technical Certificate
AA/AS
4-year College
Higher than BA/BS
Some college, no degree
16
Did you earn the above degree outside the United States?* This field is required.
YESNO
17
Choose a primary goal* This field is required.
Please select one
Please select one
Improve basic skills
Improve English skills
High School Diploma/GED
Get a job
Retain a job
Get a better job
Enter college or training
Work-based project
Family goal/personal goal
U.S. Citizenship
Military
None
Other
18
Choose a secondary goal (different from primary)* This field is required.
Please select one
Please select one
Improve basic skills
Improve English skills
High School Diploma/GED
Get a job
Retain a job
Get a better job
Enter college or training
Work-based project
Family goal/personal goal
U.S. Citizenship
Military
None
Other
19
What are some things that make it difficult to get or keep a job? Check all that apply. (You can choose more than one.)* This field is required.
English is not my native language.
I feel that I am not treated fairly at work because I am from another country.
I have limited ability to read and/or write OR I did not finish high school.
I have a physical, mental or other disability.
I was in jail.
I aged out of the foster care system.
I lost my house or apartment and I am now living in temporary housing.
I get help from government programs like CalWORKs, or I applied for my children to receive help within the last 6 months.
I am a homemaker who stays home to take care of the family. I need to get a job to earn money to help pay the bills.
I am employed or underemployed and experiencing difficulty in getting or upgrading my job.
I have been unemployed and looking for work for 6 months or more.
I am a single parent with young children under the age of 18.
I am pregnant and single.
20
Name of Emergency Contact* This field is required.
First Name
Last Name
21
Emergency Contact Phone Number* This field is required.
(###) ###-####
22
Relationship* This field is required.
23
Photo Release: I hereby authorize Milpitas Adult Education to use my photograph/video in their class brochures, on their website or other promotional materials.* This field is required.
YESNO
24
By entering my name below, I verify that all the information entered above is true and correct to the best of my knowledge. (Please type your full name below).* This field is required.
25
Appointment* This field is required.
26
**WHY DO WE ASK FOR YOUR SOCIAL SECURITY NUMBER (SSN) OR INDIVIDUAL TAXPAYER ID NUMBER (ITIN)?* This field is required.During registration, you will be asked to voluntarily provide your SSN or ITIN. This allows the school to collect your Social Security Number or Individual Taxpayer ID Number (ITIN) and share it with the California Department of Education who will share your personal information with the Employment Development Department. The Employment Development Department is the state agency responsible for maintaining personally identifiable information and keeps all information confidential it receives from the California Department of Education for use only to track the labor market outcomes of adult education program participants in compliance with all applicable state and federal laws and mandates.
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