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Citizenship
Registration Form
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone number
*
Your answer
Address (include city and zip code)
*
Your answer
Ethnicity
Hispanic
White
American Indian
Asian
Black or African American
Pacific Islander
Other
Clear selection
Email
Your answer
Economic Special needs/ Personal status Check all that apply
*
Food Stamps
Low Income
TANF/CalWORKS recipient
Child eligible for free or reduced lunch
Seasonal Farm Worker
Veteran
Single Parent
Disabled
Dislocated Worker
Migrant
Limited English Proficient
NONE APPLY
Required
Marital Status
Single
Married
Widow
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Number of dependents
*
0
1
2
3
4
5+
Number of children in grades K-12
0
1
2
3
4
5+
Clear selection
Labor Force
*
Employed
Unemployed
Not employed, seeking work
Retired
Birthplace (country)
Your answer
Family household income
*
$0-$7500
$7500-$15,000
$15,000-$50,000
$50,000-$100,000
$100,00+
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