****RT Program Use Only****
Date Received: _______________
Cumulative GPA: _____________
Science GPA: ________________
East Los Angeles College / Santa Monica College
Respiratory Therapy Program Application
Academic Year Applying for: Fall _______ Check the desired campus for Associate Degree*  ELAC or  SMC
*If accepted you will take your first year’s courses at the above selected campus and upon program completion will apply for your
Associate Degree from the above selected campus. Please note that, “general education” requirements differ at each campus.
Please type or print the following information clearly
Date of Birth:
Applicant Name:
Student ID #:
Last
First
ELAC SMC -
M.I.
Street Address:
Phone:
City, State, Zip Code
Alt. Phone:
Email:
Social Sec. #:
(Valid SS# Required for Clinical Placement Background Check)
NOTES:
Official communication will be sent to you via your email address.
Notify both campuses if any of your contact information changes.
IMPORTANT: Individuals who are accepted into the ELAC/SMC Respiratory Therapy Program must have a
clear criminal background check and a negative drug test
Have you ever attended another Respiratory Therapy Program or any program which included placement in a
clinical facility?
Yes
No
If yes, when/where:_______________________________________
Are you eligible to return to this program?
Yes
No
If No, please explain_______________________________________
Program Prerequisite Courses (must be completed with a C or better prior to application)
Institution/City/State
Course # and title
Sem/Year/Units
Grade
1. Human Anatomy w/ Lab (4**)
ELAC - ANATOMY 1 or BIO 20
SMC - ANATMY 1
2. Human Physiology w/ Lab *(4**)
ELAC - PHYSIOL 1 or BIO 20
SMC - PHYS 3
3. Chemistry Intro w/ Lab (4-5**)
ELAC - CHEM 51 or 65
SMC - CHEM 10
4. Communication (3**)
ELAC - COMM STUDIES 101 or 121
SMC - COMM STUDIES 11, 35, or 37
5. Intermediate Algebra
ELAC - MATH 125 (5**)
SMC - MATH 18 (3**) or 20 (5**)
6. Reading and Composition (3**)
ELAC - ENGL 101
SMC - ENGL 1
7. Microbiology Intro w/Lab *(4-5**)
ELAC - MICRO 20
SMC - MCRBIO 1
Program-applicable courses to
be completed prior to admission:
1. Respiratory Therapy Intro+
ELAC - RES TH 101
SMC - RES TH 1
2. Respiratory Therapy Fund+
ELAC - RES TH 2
SMC - RES TH 2
* Microbiology Intro and Human Physiology must be completed within the last 7 years at the time of admission
** Semester Units
RA updated 09/02/14
Page 1 of 3
List ALL Colleges Attended in chronological order:
College (Name and Location):
*RT Program Use Only *
Transcripts Received 
1.
2.
3.
4.
5.
6.
NOTE: An official transcript (photocopies are OK) for each college attended must be attached to the application. Applications will
not be considered unless all transcripts are attached. Upon admission to the program, official transcripts mailed from all colleges
attended will be required with the exception of LACCD/SMC transcripts. Transcripts become property of the college.
Please mark your answer to the following questions (required for accreditation, state, and federal reporting):
1. Gender:
Male
2. Are you a U.S. citizen?
Female
Yes
No
a. If no, are you in the U.S. as a Permanent Resident?
b. If no, are you in the U.S. on a Visa?
Yes
Yes
No Document#
No Type of Visa?
Visa#
c. If no to all of the above, please explain your status:
3. Are you lawfully eligible to work in the U.S.?
4. Are you currently employed?
Yes
Yes
No
No
Approx. Wage $_______/hr Hrs/week? ______
5. Are you a U.S. veteran?
Yes
No
6. Are you a qualifying spouse of a U.S. veteran?
Yes
No
7. Are you disabled?
Yes
No
8. Are you a single parent?
Yes
No
9. Are you a first generation college student?
Yes
No
10. a. Where did you attend High School?
Full Name of School
City
b. Did you receive a High School Diploma?
Yes
No
c. If no HS Diploma, do you have a GED?
Yes
No
11. Highest level of education completed:
High School
12. Home Language/s: ________________
State
Graduation Date:________________
Associate Degree
________________
Zip Code
Bachelors
Masters
________________
13. Please mark your ethnic origin/s: (mark as many as applicable)
Native American or Alaskan Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Thai
Other Asian: _________________
Native Hawaiian or Other Pacific
Islander
Black/African American
Hispanic/Latino
White/Non-Hispanic
Other Ethnicity: _____________
I certify that the answers I have given in this document are true and correct and I have not withheld any facts or
circumstances. I understand that all answers given on this document and in the application process are subject to
verification and that should I be admitted to the ELAC/SMC Respiratory Therapy Program, any falsification,
misrepresentation, or omission of facts are sufficient reason for dismissal upon discovery at any time during the program.
Signature of Applicant
RA updated 09/02/14
Date
Page 2 of 3
East Los Angeles College / Santa Monica College Respiratory Therapy Program
Application Instructions
Applications are accepted for its annual cohort once a year from February 1st to August 1st. The program
starts each year during the fall semester. Students enrolled in RT-1 and RT-2 in the spring semester may
submit an application during the open application time period, but will need to submit proof of completion
immediately following the semester. Students are selected by lottery and their names will be placed according
to their lottery number.
This program provides veterans’ priority services under the Jobs for Veterans Act. Completed applications
from U.S. veterans and the qualifying spouses of U.S. veterans receive priority for each fall class.
Documentation of veteran status or qualifying spouse status is required in order to receive priority services.
Mail all transcripts directly to the selected college admissions office, SMC or ELAC. Hand-carried transcripts of
any kind are NOT acceptable as official transcripts. In addition, applicants are responsible for verifying with the
admissions office that all transcripts have arrived prior to making a counseling appointment for evaluation of
domestic transcripts and verification of program prerequisites.
Once received by the RT program office, applications are screened to determine whether they are complete.
Prospective students will be sent notification of the screening result (Complete or Incomplete). Applicants who
submitted Incomplete applications will be provided with a checklist of items needed to complete their
application.
Applications are accepted at the following locations based on the desired campus. Applications
mailed/delivered to the incorrect campus will not be forwarded. Please be sure to submit your application to
the correct campus.
East Los Angeles College applications can be delivered or mailed to…
East Los Angeles College
1301 Avenida Cesar Chavez
Monterey Park, CA 91754-6099
ATTN: Respiratory Therapy Program Office, Bungalow C2-126A
Santa Monica College applications can be mailed to…
Santa Monica College
1900 Pico Blvd
Santa Monica, CA 90405
ATTN: Health Sciences, Respiratory Therapy Program Office
Santa Monica College applications can be delivered* to…
Santa Monica College Bundy Campus, 3rd Floor Health Sciences Office
3171 S. Bundy Dr.
Los Angeles, CA 90066
*applications mailed to this address will be returned to sender by the US Postal Service
RA updated 09/02/14