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22351 City Center Drive
Hayward, CA 94541
(510) 582-2182
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8105 Edgewater Drive, Suite 270
Oakland, CA 94621
(510) 244-0966
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(Located in the Fremont Family Resource Center)
39155 Liberty Street, Room D410
Fremont, CA 94538
(510) 582-2182
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Academic Training Verification
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Academic Training Verification
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Personal Information
Parent Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
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Delaware
District of Columbia
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State
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Phone
Email
*
Specialist Name
Source of Income
Source of Income
Unemployment
Child Support
Other
Unemployment $
Child Support $
Other
Other $
Academic Goal
Main Education or Training Goal
Prepare for a new career (acquire new job skills)
Advance in current job/career (update job skills)
Improve Basic skills in English, Reading or Math
Complete credits for High School Diploma/GED
Obtain a Vocational Certificate
Obtain a two-year Vocational Degree
Obtain a two-year Associate Degree
Obtain a Bachelor's Degree
Obtain a Master's Degree
Maintain a certificate or license
Other
Other (Please Specify)
Field of Study
Career goal upon completing education
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School Information
School Name
School Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date Current Term Begins
Date Current Term Ends
Expected Date of Completion
Class Schedule(s)
Course Name
Course Number
Units
Days
M
T
W
Th
F
Time In
Time Out
Course Name 2
Course Number (Course 2)
Units (Course 2)
Days (Course 2)
M
T
W
Th
F
Time In (Course 2)
Time Out (Course 2)
Course Name 3
Course Number (Course 3)
Units (Course 3)
Days (Course 3)
M
T
W
Th
F
Time In (Course 3)
Time Out (Course 3)
Course Name 4
Course Number (Course 4)
Units (Course 4)
Days (Course 4)
M
T
W
Th
F
Time In (Course 4)
Time Out (Course 4)
Course Name 5
Course Number (Course 5)
Units (Course 5)
Days (Course 5)
M
T
W
Th
F
Time In (Course 5)
Time Out (Course 5)
Failed Course/Courses to be Repeated
Course Name
Grade
Class Start Date
Class End Date
Course Name 2
Grade (Course 2)
Class Start Date (Course 2)
Class End Date (Course 2)
Course Name 3
Grade (Course 3)
Class Start Date (Course 3)
Class End Date (Course 3)
Course Name 4
Grade (Course 4)
Class Start Date (Course 4)
Class End Date (Course 4)
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