Mail-in Registration Form - San Mateo Adult School

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					                                        SAN MATEO ADULT SCHOOL REGISTRATION FORM
                                                                       Please Print Clearly
Have you attended San Mateo Adult School before? Yes ___ No ___

Student ID# ___ ___ ___ ___ ___ ___ ___ ___ ___ Birthdate (month) _____ (day) _____ (year) ______ Sex: M ___ F ___
Last Name                                                               First                                                       Middle
                               Street                                   Apt. #                               City                                Zip Code

Telephone H (             )                              Cell (         )                              Email: __________________________________
Emergency Contact Information:
Name: ___________________________________ Relationship ___________________ Phone No.

Education: Number of years of school completed (circle the highest completed):                            1 2 3 4 5 6 7 8 9 10 11 12 College
Highest school level or diploma earned (circle one):   None                      HS Diploma                 GED Certificate            Technical/Certificate
          Some college but no degree     A.A./A.S. Degree                        4 yr. College Graduate     Graduate Studies           Other ________________

Majority of Education outside United States: Yes or No (circle one)                                              Country of Origin: ________________________

          Ethnicity                                                  Labor Force Status                            Student Goals (mark two)
                   White                  Pac. Islander                     Employed
                   Hispanic               Ameri. Indian                     Unemployed                                1 = Primary     2 = Secondary
                   Black                  Alaskan Nat.                      Not employed and
                   Asian            Other:                                  not seeking work                                Get a job
                   Filipino                                                 Retired                                         Retain a job
                                                                                                                            H.S. Diploma/GED
                                                                                                                            Enter College or Training
          Native Language                                            Student Type                                           U.S. Citizenship
                      English                 Portuguese                    CalWorks                                        Improve English Skills
                      Arabic                  Russian                       Concurrently Enrolled                           Community Involvement
                      Chinese                 Spanish                       in High School/K12                              Computer Skills
                      Farsi                   Tagalog                       Disabled                                        Military
                      Hindi                   Thai                          General Assistance                              Family Goal/Parenting
                      Japanese                Vietnamese                    Veteran                                         Improve Basic Skills
                      Korean                  Other                         WIA                                             Personal Goal
                                                                            Other                                           Other

New Classes
        Section(s)                        Course(s)               Day(s)/Time                Teacher                 Room             Start date                Fees
    /     /    /      /    /                                            /                                                                    /
    /     /    /      /    /                                            /                                                                    /
    /     /    /      /    /                                            /                                                                    /
    /     /    /      /    /                                            /                                                                    /

Refunds are ONLY given if a class is cancelled.                   Form of payment: Cash, Check or Credit Card (circle one) Total Paid $
MAKE CHECKS PAYABLE TO: San Mateo Adult School (One check per class) - Check Number(s):_______ _______________

Visa/MC Card number:                                      -                          -                       -                         Exp. Date            /
Credit card transactions listed as SMUHSD (San Mateo Union High School District).
Student’s Signature                                                                          Date:
Your signature authorizes San Mateo Adult School to share your educational information with other academic institutions.
This form is not verification of attendance                                                               ESL Orientation Date: ____________________
Office Use Only:       ADA type: ESL or Regular Adult (circle one)
                       ASAP:                         Date:                            TopsPro:                      Date:                         Rev. 11/08/12

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