Division of Adult Education Form A-25 Rev. 06/13 STUDENT REGISTRATION/ RESIDENCE AFFIDAVIT

Adult Education Student I.D. No. Número de identificación escolar del alumno

5.

Majority of my schooling was outside U.S.

Grade Level (grado escolar): Highest year of school Completed: (grado más alto de escolaridad):

1.

-

Yes (sí) 

No (no) 

Last Name (Apellido)

6. First Name (Nombre)

Middle Name (Segundo nombre)

Address (Domicilio)

City (Ciudad)

GED Certificate High School Diploma Technical Certificate

State (Estado)

) Home Phone

Número de teléfono en casa

(

/ Month (mes)

Day (día)

Some College No Degree AA/AS Degree 4 Yr. College Graduate

Graduate Studies None Other

Zip Code (Código Postal)

) Work Phone

(



(Estado civil): M /C  S/S 

No (no) 

10. No. of dependent

) Cell Phone

Número de teléfono en el trabajo

8. Marital Status:

Education outside the US? (¿Estudió fuera de EU?) Yes (sí)

Date of Birth (Fecha de nacimiento)

(encerrar uno en un círculo):

Número de teléfono de celular

9.

children under 18: (Número de dependientes menores de 18 años):

Annual Income (Circle One): Ingresos anuales (encerrar uno en un círculo):

Gender: Género (masculino o femenino)

/ Year (año)

M



F



2. Circle all that apply to you: (encerrar en un círculo los que correspondan) Apprenticeship Adult Sch. High School Diploma CalWorks Concurrent Enrollment with High Sch. (CE) District Employee GED GI Bill

Fall

Spring

Summer

FOR OFFICE & OFF SITE TEACHER USE ONLY

Para uso de la oficina: Concurrent H.S. Student: (Current Grade) __________

________________________ SECTION NO. FOR CLASS 1

________________________________ 7.

E-Mail Address (Correo electrónico) (

Highest Educational Level

SEMESTER:

-

Low Income Public Assistance Rehabilitation Special Needs or Disabled Unemployment Veteran

Course

________________________________ Teacher

________________________________ Location/Room

________________________________ Days & Times

________________

___________

IF MARRIED, (SI ES CASADO): Is your annual income less than $28,694? (¿Percibe un ingreso anual menor de $28,694 dólares?) Yes (sí)  No (no) 

11. Labor Force (Circle One):

Employed

Empleado

IF SINGLE, (SI ES SOLTERO): Is your annual income less than $21,257? (¿Percibe un ingreso anual menor de $21,257 dólares?)

Unemployed

Desempleado

____________________________________ SECTION NO. FOR CLASS 2

Unemployed & not seeking work

Desempleado y no busco trabajo

________________________________

Retired

Jubilado

________________________________

Yes (sí)



No (no) 

Fuerza laboral (encerrar uno en un círculo):

Fees Paid

Foreign Tuition

Assigned by: ___________________________

Course

Teacher

3. Race (Check all that apply):

12. Native Language (encerrar uno en un círculo)

4. Ethnicity (etnia):

Raza (marcar los que correspondan):

(Idioma natal (encerrar uno en un círculo): Hispanic or Latino

White African American Asian Filipino Pacific Islander American Indian Alaskan

      

Not Hispanic or Latino

________________________________

 

Location/Room English Chinese Tagalog Russian

Spanish Hmong Korean Farsi

Vietnamese Cambodian Lao Other

________________________________ Days & Times

________________

AFFIDAVIT-VERIFICATION OF ADULT EDUCATION STUDENT RESIDENCY I declare under the penalty of perjury that I reside at the street address above. I agree to notify the adult school Within two (2) weeks when residency has been changed either within or outside of the State of California. I understand that if I reside outside of the State of California I must pay non-resident tuition. Declaro so pena de perjurio que resido en el domicilio escrito arriba. En caso de haber un cambio de domicilio dentro o fuera del estado de California, estoy de acuerdo en notificar a la escuela de adultos dentro de un período no mayor de dos (2) semanas. Tengo entendido que si resido fuera del estado de California debo pagar colegiatura como no-residente.

Fees Paid

___________ Foreign Tuition

Assigned by: ___________________________ Affidavit entered by:

______________

Test Scores:

X____________________________________________________________ Student Signature (If minor or Concurrent Enrollment student, parent must sign) Firma del alumno (Firma del padre si se trata de un menor o de inscripción simultánea)

_________________________ Date (Fecha)

ESL:

L _________

R __________

TABE: Form: _______ Score:________