WLAC Program Interest Form
Program Interest Form
Participant Information
Last Name
*
First Name
*
Middle Name
/
/
CA
AK - Alaska
AL - Alabama
AP - Armed Forces Pacific
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - Washington DC
DE - Delaware
FL - Florida
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - U.S. Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Birth Date (Format MM/DD/YYYY)
*
Street Address
*
City
*
State
*
Zip Code
*
-
-
Contact By:
Email
Phone Call
Text
Phone
*
Enter 2nd Phone
Email Address
*
Enter 2nd Email
(Mark All That Apply)
No
Yes
Do You Have A LACCD Student ID?
*
Student ID
(Format: 881234567 or 900000000)
Program Of Study
(Mark All That Apply)
1. NC - Custodial Technician Training Program
2. NC - Administrative Assistant Training Program
3.NC - In-Home Health Supportive Services Training
4. Healthcare Career Discovery Certificate
Addiction Studies
AS-T in Health Sciences
AS-T in Public Health
Autism Technician
Bachelor Degree Completion Program
BS Degree in Dental Hygiene
CE Courses
Certified Nursing Assistant/Home Health Aide
Dental Assistant
Emergency Medical Technician
Health Science Foundation Certificate
Healthcare Exploration
Healthcare Services
High School - IGETC/CSU Transfer
In-Home Support Services Provider (IHSS)
Kinesiology Majors
Medical Assistant
Paramedic
Pharmacy Technician
Public Health
RDHAP
Demographics
Female
Male
Transgender
No
Yes
Gender
Hispanic Or Latino
Race:
Asian
American Indian/Alaskan Native
Black or African American
Native Hawaiian or Pacific Island
White
(Mark All That Apply)
Employment & Income Information
No
Yes
Employed
*
Education
No
Yes
Are You A Middle School Or High School Student?
6th
7th
8th
9th
10th
11th
12th
High School Name
City (High School Location)
Grade Level
Special Background
No
Yes
No
Yes
No
Yes
U.S. Veteran
Spouse Of U.S. Veteran
Registered For Selective Service
No
Yes
Disabled As Defined By American Disabilities Act (ACA)
* Required