Section 1 of 1 in this document
Phone Number
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Coachella Valley Adult School Registration FormÂ
2022-2023
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Hi there!! To enroll in Coachella Valley Adult School please answer the following questions . Feel free to give us a call 760-398-6302 if you need assistance. Thank you and have a great day!!
Full Name
First Name
*
Last Name
*
Email
Full Address
Street Address
*
City
*
State
*
Zip
*
What class would you like to enroll in?
High School Diploma
GED / HiSET preparation
Real Estate License
Computer Classes
Citizenship
English (ESL)
Quickbooks
Public Notary
Loan Signing Specialist
If you are enrolling in GED/ HiSet Preparation, please select the language preferred.
English
Spanish
If you are enrolling in English classes (ESL), please select a Level.
Level 1
Level 2
Level 3
Level 4
Would you prefer morning or evening classes?
Morning Classes
Evening Classes
Name of current or previous teacher? (not required)
What school district did you last attend school in?
Coachella Valley Unified School District
Desert Sands Unified School District
Palm Springs Unified School District
Not Sure
Name of last school attended
*
Date of Birth
Month
*
MM
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
DD
01
02
03
04
05
06
07
08
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11
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15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
YYYY
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
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1974
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1971
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1960
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1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Age
*
Gender
Male
Female
Non Binary
Marital Status
Married
Single
Divorced
Separated
Widow
Are you pregnant or have children under 18?
Yes
No
Number of children in school grades K-12
*
Choose One
0
1
2
3
4
5
6
7
8
9
10
Does your child receive free or reduced cost lunch
Yes
No
Employment Status
Employed
Unemployed
Retired
Disabled
Please indicate the size of you family
*
Choose One
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Please indicate your monthly income
*
How many years did you attend school?
*
Choose One
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Please indicate the last year you attended school.
*
Do you have education from outside the USA?
Yes
No
Please indicate your highest level of education.
None
GED Certificate
High School Diploma
Technical Certificate
Some College
AA Degree
BA/BS Degree
Graduate degree (Masters or Doctorate)
Ethnicity
Hispanic/Latino
Not Hispanic / Latino
Race
White
Asian
American Indian
Alaska Native
Black or African American
Native Hawaiian or Pacific Islander
Language Spoken at Home
*
Please indicate you primary goal for attending Coachella Valley Adult School
Get a job
Get a better job
Keep my job
Get a High School Diploma or GED
Work based project
Family goal
Personal goal
Obtain U.S. citizenship
Join the military
Enter college or training
Improve English skills
Improve basic literacy skills
Please indicate you secondary goal for attending Coachella Valley Adult School
Get a job
Get a better job
Keep my job
Get a High School Diploma or GED
Work based project
Family goal
Personal goal
Obtain U.S. citizenship
Join the military
Enter college or training
Improve English skills
Improve basic literacy skills
Please indicate you personal status below
GAIN
Cal Learn
WIC
Homemaker
Other public assistance
Teen parent
Single parent
ARRA
Rehabilitation
WIA
Handicapped / Disabled
Special Education
Dislocated Worker
TANIF
SSI
Homeless
Coachella Valley Rescue Mission
Migrant and Seasonal Farm Worker
Seasonal Farm Worker
Veteran
None of the above
Please select all the devices you have access to at home.
Computer
Laptop
Tablet
iPad
Chromebook
Smart Phone
Do you have access to Wi-Fi Internet at home?
Yes
No
What type of class are you most interested in?
Online
In person
Blended (online and in person)
Have you lost employment due to the COVID-19 Pandemic
Yes
No
Emergency Contact- Name
*
Emergency Contact- Phone Number
*
Emergency Contact- Relationship
*
How did you hear about Coachella Valley Adult School
Radio
Website
TV
Friend or Family
Sign or Banner
Upload High School Transcript (optional)
Click Here to Upload
Sign Here
Sign Here
First Name
Last Name
Email
Choose how to sign
Draw
Type
Email
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