Application For Admission - Los Angeles Community College District Page 2
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1
2Revised 03/2014
24. Highest Education Status: Please enter number and year in boxes below
19. What is your primary language? (*) Please enter one number in box
1
= Earned a U.S. High School diploma (or will earn one before college semester begins)
1
= English
5
= Filipino
2
= Enrolled in grade 12 or below when college semester begins
2
= Armenian
6
= Japanese
9
= Spanish
3
= Not a High School graduate, currently enrolled in adult school
3
= Chinese
7
= Korean
10
= Vietnamese
4
= Not a High School graduate, last attended High School
4
= Farsi
8
= Russian
11
= Other language
5
= Passed the GED or received a certificate of H.S. equivalency
Number
6
= Earned California High School Proficiency Certificate
7
= Earned a Foreign Secondary diploma or certificate of graduation
8
= Earned an Associate degree
= Earned a Bachelor’s or higher degree
Year
9
25. Enrollment Status: Please enter number in box
20. What is your main educational goal? Please enter one number in box
1
= First time college student
1
= Prepare for a new career (acquire new job skills)
2
= First time at this college, after attending another college
2
= Advance in current job/career (update job skills)
3
= Returning to this college, after attending another college
3
= Discover/develop career interests, plans and goals
4
= Returning to this college, without having attended another college
4
= Obtain a two-year vocational degree without transfer
10
= Improve basic skills in English, reading or math
th
5
= Enrolling in this college, while attending school in the 12
or lower grade
5
= Obtain a two-year Associate degree without transfer
11
= Complete credits for high school diploma or GED
6
= Obtain a vocational certificate without transfer
12
= Personal development (intellectual, cultural)
26. College Units or degree completed by first day of this term
= Obtain a Bachelor’s degree after completing an
7
13
= Undecided on goal
Associate’s degree
Please enter number in box
= Obtain a Bachelor’s degree without completing an
8
14
= To move from noncredit coursework to credit
1
= 0 units
4
= 30 to 59 ½
Associate’s degree
coursework
2
= 1 ½ to 15 ½
5
= 60 or more units, no degree
9
= Maintain certificate or license (e.g. Nursing, Real Estate)
15
= Complete 4 year college requirements
3
= 16 to 29 ½
6
= A.A., A.S., B.A., B.S. or higher degree
21. Special Services (*)
27. Student Information -- Permission to Release
The Los Angeles Community College District is committed to increasing your educational success. Each area listed below provides
TYPES OF STUDENT INFORMATION: According to the Los Angeles Community College District (1)
special services. Please indicate those services that interest you
Directory Information: Includes your name; city of residence; participation in officially recognized activities and
□
□
1
6
Financial Aid
Information regarding special services and/or accommodations for students with
sports; weight and height of athletic team members; dates of attendance; degrees and awards received; and the
□
2
disabilities may be obtained from the Disabled Student Programs (DSPS) Office.
most recent previous educational institution attended. (2) College Foundation Information: Includes your name,
Child Care
□
address, and telephone number. 3) Four-year College Information: Includes your name, address, and telephone
3
7
Are you from a low income family and in need of special counseling, tutoring, and/or
Tutoring
number. 4) Military Recruiting Information: Includes “Directory information” plus address, telephone number,
□
□
□
4
financial aid assistance?
Yes
No
Transfer Assistance
date of birth, and major field of study.
□
□
5
8
Employment
I am a former or current foster youth and am interested in financial aid and/or other
I do not permit the college to release directory information
Assistance
benefits & services available to foster youth.
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(Leave blank if you want information on LACCD Foundation scholarships, grants, and
22. Foster Youth (Please enter number in box).
networking opportunities)
0
= I have never been in Foster Care.
I do not permit the release of information to the College Foundation
1
= I am currently in Foster Care in California.
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2
= I was previously in Foster Care in California, and aged out or emancipated from the system.
I do not permit the release of information to four-year colleges
3
= I am currently in Foster Care in a system outside California.
I do not permit the release of information to the military
4
= I was previously in Foster Care in a system outside California, and aged out or emancipated from the system.
You may change your Directory Release at any time by completing a Release of Directory Information form and
5
= I was previously in Foster Care, but did not age out or emancipate from the system.
returning it to the Admissions Office.
23. Veteran (Complete only if you are a Veteran, Spouse and/or Dependent of a Veteran).
28. Parent 1’s Highest Education Status
:
□
□
Not Honor Veteran
Honor Veteran Date you were honorably discharged: Month ________ Day _______
Year ________
th
1 = 9
grade or less
□
□
None Apply to me
Veteran (active or reserve) discharged within the last year
2 = Some high school
□
□
3 = High School Graduate (diploma, GED or equivalent)
Currently active military
Veteran (active or reserve) discharged over a year ago
Parent 2’s Highest Education Status:
□
□
Dependent spouse or child of currently active military
Currently in Reserves
th
1 = 9
grade or less
□
□
2 = Some high school
No……Currently Military Active
Yes
State of legal residence:
.
3 = High School Graduate (diploma, GED or equivalent)
□
□
Yes
No……Currently Military Reserve
NON-DISCRIMINATION POLICY
□
□
Yes
No…… Currently National Guard
Home of Record:
.
All programs and activities of the Los Angeles Community College District shall be operated in a manner which
□
□
No……Parent is Military Active
Yes
is free of discrimination on the basis of race, color, national origin, ancestry, religion, creed, sex, pregnancy,
□
□
maritial status, sexual orientation, age, handicap or veterans status (Reference: Board Rule, chapter 15)
Yes
No…… Parent is a Veteran
Country of Record:
.
□
□
No……Parent is a Military Reserve
Yes
In order to ensure the proper handling of all civil rights matters, each college in the District has its own Diversity
□
□
□
□
No……Parent is National Guard
Currently stationed in CA ……….
program, Title IX/Sex-Equity Coordinator, Section 504 Coordinator of Handicap Programs, and an
Yes
Yes
No
Ombudsperson. Direct initial inquiries to the Office of Diversity Programs at (213) 891-2000.
CERTIFICATION
* Responses to questions marked by this symbol will be used to provide you with information on college programs and
I declare under penalty of perjury that all information on this form is correct. I understand that falsifying or
services and/or for statistical purposes only. Refusal to provide this information will not be used to deny admission to the college or any
withholding information required on this form shall constitute grounds for dismissal.
of its programs. If additional information is needed to determine your residence status you will be required to complete a supplemental
REQUIRED
residence questionnaire and/or to present evidence in accordance with Education Code sections 68040 et seq. The burden of proof to
SIGNATURE
______________________________________________________Date______________
clearly demonstrate both physical presence in California and intent to establish California residence lies with the student.
Revised: 3/2014
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