WLAC Program Interest Form
Program Interest Form
Participant Information  
Last Name * First Name * Middle Name
 /  / 
Birth Date (Format MM/DD/YYYY) * Street Address * City * State * Zip Code *
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Contact By:
Phone *
Email Address *
(Mark All That Apply)
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
In-Home Support Services Provider (IHSS)
Kinesiology Majors
Medical Assistant
Paramedic
Pharmacy Technician
Public Health
RDHAP
Demographics  
Gender Hispanic Or Latino
Race:
(Mark All That Apply)
Employment & Income Information   
Employed *
Education  
Are You A Middle School Or High School Student?
High School Name City (High School Location) Grade Level
Special Background  
U.S. Veteran Spouse Of U.S. Veteran Registered For Selective Service
Disabled As Defined By American Disabilities Act (ACA)
* Required