LOS ANGELES CI TY COL LEGE
COLLEGE READINESS ACADEMY
Please complete all the information on this application to the best of your knowledge. We look forward to helping you
reach your goals in life.
Student ID #: 88 -____________________
S TUDE NT I NFO RM ATI O N
___________________________________________
Last Name
____________________________________
__________
First Name
Middle Initial
Street Address __________________________________ Apt.# _______ City _____________________ Zip___________
D.O.B.
/_______ / ________ Age _______
Cell Phone # (
Gender:
) __________________________
MALE
FEMALE
Home Phone # (
Veteran:
Yes
No
) ____________________________
Email Address ______________________________________________________________________________________
MARITAL STATUS:
Single
Married
Separated
Divorced
Widowed
Please select your ethnic identity below:
Alaskan Native/American Indian
Chicano/Latino/Hispanic
Asian/Pacific Islander
Multi-ethnic/racial
Black/African-American
Other ________________________________
Caucasian, White
Referred by:
CalWORKs Office
Do you need preparation for
When do you prefer to take classes
Counseling Office
G E D E x am
Financial Aid Office
Ba si c S k il ls
Mornings
EOP&S
Other: ________
C AH S E E (High School Exit Exam)
Afternoon
Have you taken the placement test at LACC?...............................
No
Yes: Results: Math ___ Eng._____ Taken:____
Are you currently enrolled at LACC? .............................................
No
Yes: Number of units
Do you want to transition to a credit program? .............
No
Yes:
Would you like Tutoring? ….............................................
No
Yes:
benefits?
No
Yes
Do you need Financial Aid Assistance? …………….
No
Yes
Do you need child care? .................................................................
No
Yes:
Are/were you a foster youth? ..........................................
Yes
Are you receiving AFDC/TANF CalWORKs cash
No
Do you have a disability? ..............................................................
No
Yes: What
Are you currently working? ……………………………..... Number of hours per week
Pre assessment level: _________ Score:_________
Post assessment level:________ Score:_________
C oll ege Re adi n es s Pr og ram — L o s An gel es Cit y C oll eg e (Wilshire Center)
323 953-4000 ext. 2582
323-953-4013 fax
3020 Wilshire Blvd., CCW-254 Los Angeles, CA 90010
_
LOS ANGELES CI TY COL LEGE
COLLEGE READINESS ACADEMY
STUDENT SUCCESS AGREEMENT
If accepted as a student in the LACC College Readiness Academy Program I agree to:
 Enroll and complete the semester.
 Attend a mandatory ORIENTATION.
Orientation Date:_________________
 Take a PRE ASSESSMENT TEST at the
beginning of the semester.
Assessment Date:_________________
 Attend all WORKSHOPS,
Online and On Site.
Date of Workshop:________________
 Meet with a Counselor to discuss
Educational and Career goals
at least twice a semester.
Date with Counselor:______________
 Complete 10 HOURS of tutoring
per semester.
Completion of Hours:______________
 Take a POST ASSESSMENT TEST at
the completion of the class.
Assessment Date:_________________
 Transition to the FYE program.
Transition Date:____________________
 Notify office staff if exiting the program.
I will commit myself to the following:
“Make my education a priority. Do my best to complete the entire school year. Take at
least 2 classes per semester. Make a real effort not to miss any classes. Only drop a class after
talking to my counselor. Complete my class assignments as required. Participate in occasional
evening and Saturday programs.”
Student Signature ________________________________________________ Date________________
C oll ege Re adi n es s Pr og ram — L o s An gel es Cit y C oll eg e (Wilshire Center)
323 953-4000 ext. 2582
323-953-4013 fax
3020 Wilshire Blvd., CCW-254 Los Angeles, CA 90010