Outreach & Recruitment

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Prospective Student Information

Last Name *

First Name: *

Street Address/Apartment Number: *

City: *

State: *

Zip Code: *

Phone Number: *

Email: *

Date of Birth: *

YYYY

Sex: *

Female

Male

Decline to state

High School Graduation Year *

Name of High School: *

If your high school is not listed, please specify:

Projected Major: *

Academic Goal: *

Associates Degree

Transfer to a 4-year college

Certificate Program

Required

Projected Enrollment Term - Semester, Year: (Ex: Fall 2019) *

Support Service Request: *

First Year Experience (FYE)

Educational Opportunities Programs & Services (EOP&S)

TRIO

Guardian Scholars

Office of Special Services (OSS)

CalWORKS

Other:

Required

Are you Hispanic or Latino/a? *

Yes

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