New Adult Programs Application

Ethnicity: Are you hispanic or Latino?

Yes No Not Selected

Race: Indicate what you consider your race to be

AFRICAN AMERICAN

ALASKAN NATIVE

AMERICAN INDIAN

ASIAN

FILIPINO

OTHER

PACIFIC ISLANDER

WHITE

HISPANIC

Please check up to 5 categories

Do you have a computer or chromebook?

Yes No Not Selected

Have you been CONVICTED, at any time, of any crime, other than a minor traffic violation? (You need not disclose any marijuana-related offenses specified in the marijuana reform legislation and codified at the Health and Safety Code, Sections 11361.5 and 11361.7).

Yes No Not Selected

Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled, cancelled, suspended, etc.) against you?

Yes No Not Selected

If yes, indicate the type and number of license/certificate:

Education

Please answer yes or no for each option below.

Advertisement-How did you hear about us

Yes No Not Selected

Career Center-How did you hear about us

Yes No Not Selected

Friend/Relative-How did you hear about us

Yes No Not Selected

Instructor-How did you hear about us

Yes No Not Selected

Previously Enroll.-How did you hear about us

Yes No Not Selected

Relationship to Student

Parent/Guardian

Spouse

Friend/Relative

Other

Do you have a Health Insurance Provider?

Yes No Not Selected

Do you give permission for medical treatment in the event of an emergency?

Yes No Not Selected

Please describe any limitations you have that are related to your disability.

Please describe any accommodation(s) being requested.

This does not mean all accommodations will be approved. Accommodations will be based on the disability and documentation provided.

Single Head of Household/Single Parent

Yes No Not Selected

CRY-ROP

Adult Programs Application

Initial Interview Questions

Education

Emergency Contact Information

Health/Disability Information

Economic Information