Thank you for your interest in our Student Support Services program!  Please complete this application as thoroughly as possible.  You cannot save and restart this application.  You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application.  If you have any questions, please email us at

Student Information:
Last Name: *
First Name: *
Middle Name:
Date of Birth: *
Describe your primary reason for applying: *
Address: *
Address 2:
City: *
State: *
Zip Code: *
Home Phone *
Cell Phone Number: *
LACCD Student Email Address: *
Student ID *
Attached copy of college ID.
Student Background:
Marital Status
Are you a single parent?
Is English your first language?
If no, What is your primary language?
Are you currently employed?
If yes, how many hours each week?
Have You Received a Bachelor's Degree? *
Mother's Educational Level *
Father's Educational Level *
Have you applied for financial aid? *
(Note: Documentation will be obtained from Financial Aid office)
Are you receiving services from the LAVC Services for Students with Disabilities program (SSD)? *
Attached copy of documentation of your LAVC SSD Verification ex. Letter/Ed. Plan. (If applicable)
Total taxable income reported on Federal income tax Return during the most recent year: *
Total Number of people supported by this income: *
Please Attach a copy of your most recent federal income tax return ** BLOCK OUT SOCIAL SECURITY NUMBERS AND BANK ACCOUNT NUMBERS BEFORE UPLOADING
If you did not file an income tax return for the most recent tax year, please indicate your source(s) of income by placing a check in the appropriate box(es) below:
Social Security
Veteran Benefits
Other (Specify):
Educational Needs & Interests – Mark all that apply
Academic Counseling
Study Skills
Financial Aid Assistance
Career Counseling
Cultural Activities
Personal Counseling
Transfer Information
College Visits
Class Scheduling
College Information
Is this the first college you have attended: *
If no, name(s) of other colleges attended:
Date you enrolled at Los Angeles Valley College: *
Current College Status: *
Number of Credits enrolled this semester *
Educational Background
High School Attended:
Year of Graduation
Date of HISET/GED:
(What is the highest grade you completed?)
High School GPA:
College GPA:
Have you been out of school 5 yrs. or more?
Year you last attended school?
Attached copy of High School or College transcripts.
Are you in any of the following campus programs? Check off all programs that apply:
Cal Works
Valley Promise

I certify that all the information I have provided is true and correct. I understand the TRIO/SSS staff will use the data provided on these forms to assist in assessing academic needs, and that all of the information will be kept confidential.

I give my permission to the TRIO/SSS staff to review, release, obtain, and/or make copies of all necessary documents to determine my needs and eligibility for the program in order to provide essential services and enhance the effectiveness of the program and/or my success.
To assure my academic success, I give my permission for the TRIO/SSS staff to contact my instructors to determine my progress. The information will be shared with me and used to determine if additional help is needed.
I agree to provide follow up information and to allow LAVC to request future college transcripts after I transfer or graduate.
I give my permission to use photographs, quotes or statements in any publications for Student Support Services. I understand that this ELECTRONIC SIGNATURE is a legal representation of my signature. *

Please select a signature verification type.