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:

General Information:
First Name: *
Middle Name
Last Name: *
Date of Birth: *
Gender: F=Female M=Male *
School ID *
Local Address *
Local Address 2
Local City *
Local State *
Local Zip *
Local Phone
Cell Phone Number: *
School Email Address: *
Preferred Contact Method *
Marital Status: M=Married S=Single *
Check if you are a U.S. Citizen or Permanent Resident:
Financial Aid Recipient *
Filed 2020 Income Tax *
Receive services from Disabled Students Program and Services (DSPS) *
Single Parent *
Independent Student (24 years of age or older, married, have children, veteran filed status, orphans or ward of the court) *
Ethnicity: Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) *
Race: Asian *
Race: Black or African American *
Race: Hawaiian or other Native to Pacific Island *
Race: White *
Race: American Indian or Alaskan Native *

Academic Information:
Current Grade Level: *
Major: *
How many units are you taking? *
How's your academic standing? *
Please list the services you are interested in receiving (Academic support/enrichment, Personal support/counseling, Career Counseling, Transfer Information, Tutoring Services, Financial Aid Information, University Field Trip/cultural events) *
Educational Plans (Please type all that apply: AA degree, Transfer with AA, Transfer without AA, Certificate, Other...) *
How did you hear about us? *
Are you in any of the following campus programs (Type all that apply: EOP&S, STEM, CalWorks, DSPS, Metas) *

Family Information:
How many people in your household at home? *
Family Income Range:
Your natural/adoptive/step father Educational Level:
Your natural/adoptive/step mother Educational Level:
Most Recent IRS 1040

Sign and Submit:
Terms of Submission:
By submitting this application, you acknowledge that all of the above information is correct and accurate to the best of your understanding.
Applicant Signature *
Please select a signature verification type.
*Student Support Services Program at Los Angeles Mission College is 100% federally funded by the U.S. Department of Education*