Student ID # I attended Torrance Adult School before: ☐ Yes ☐ No

Torrance Adult School - Student Enrollment Information

Sex: ☐ Male ☐ Female ☐ Other

Last Name (Print) First Name (Print) MI
Address:
Number Street Apt#
City: Zip: Birth Date - - Ph: ( ) -
Month Day Year ☐ Home ☐ Wk ☐ Cell
Email:
Are you Hispanic or Latino? ☐ Yes ☐ No
Ethnicity/Race: (Mark one or more):
☐ White ☐ Asian ☐ Black ☐Filipino ☐ American Indian ☐ Pacific Islander/Hawaiian ☐ Alaska Native
Native Language:
☐ English ☐ Spanish ☐ Vietnamese ☐ Chinese ☐ Hmong ☐ Cambodian
☐ Tagalog ☐ Korean ☐ Lao ☐ Russian ☐ Farsi ☐ Other
Circle highest year of school you completed: Elementary: 0 1 2 3 4 5 6 7 8 Secondary: 9 10 11 12 Post-Secondary: 13 14 15 16 +
☐ Earned outside the U. S.

What is your highest educational level? ☐ 2 Yr College Degree (AA) Employment Status
☐ None ☐ Technical Certificate ☐ Employed
☐ HSE Certificate (HiSet, GED, TASC) ☐ 4Yr College Graduate ☐ Unemployed
☐ High School Diploma ☐ Graduate Studies ☐ Not employed and not seeking work
☐ Some College (No degree) ☐ Earned outside the U.S. ☐ Retired

Section # 1 Course Title Pmt. Amt.

Section # 2 Course Title Pmt. Amt.

What are your goals for this school year?

Mark all that apply Barriers to Employment Mark ALL that Apply
☐ Improve basic literacy skills ☐ Cultural Barriers ☐ Long-term Unemployed
☐ Improve English skills ☐ Disabled ☐ Low Income - Below $15,782
☐ H.S. Diploma/HSE Type: Add $5,616 for each additional family member
☐ Get a job ☐ Displaced Homemaker ☐ Low Literacy / Math
☐ Retain a job ☐ English Language Learner ☐ Migrant Farmworker
☐ Enter college or training ☐ Ex-Offender ☐ Single Parent
☐ Work-based project ☐ Foster Care Youth ☐ Seasonal Farmworker
☐ Family goal ☐ Homeless ☐ Other Barriers:
☐ U.S. Citizenship
☐ Military Status / Public Assistance Mark ALL that Apply
☐ Personal goal ☐ Dislocated Worker ☐ SSI
☐ Other ☐ Food Stamps / Cal Fresh / SNAP ☐ U.S. Veteran
☐ Get a better job ☐ Free and Reduce Lunch ☐ WIOA: ☐ l ☐ lll ☐ lV
☐ Enter short-term training ☐ No TANF - CalWORKs within 2 years. ☐ Other Public Assistance
☐ Get off TANF or other Public Assistance ☐ TANF - CalWORKs ☐ None of the Above
All students must mark this area: Grants & Financial Assistance
☐ Limited English Proficiency (LEP) ☐ BOGG (Board of Governor's Grant) ☐ General Assistance (GA)
☐ Economically Disadvantaged/Low Income ☐ Bureau of Indian Affairs ☐ Pell Grant
☐ Medi-Cal ☐ CalWORKs
Emergency Contact Information
Contact Name: Relationship: Contact Phone:
☐ Home ☐ Wk ☐ Cell
By signing this form, I agree to the Internet Agreement on the TAS website under the Terms of Use and the photo Release Agreement in the Catalog.
*If you do not agree to the Photo Release agreement, please submit a letter to the Torrance Adult School Administrator.
By signing this form, I allow my school information to be shared with other educational/career institutions.

Student Signature: Date:

Rev 10/16/18 Entered by: Date: