Required Fields are denoted by a red asterisk(*).

*Los Rios Student ID 

*Date of Birth 

*High School 

*Last Name 

*First Name 

Middle Initial 

*Street Address 

Apt # 

*City 

*State 

*Zip Code 

*Phone/Cell Number 

*Email 

*Gender  Female   Male

Ethnic Origin
American/Alaskan Native   Asian/Pacific Islander   Black/African   Caucasian/White   Hispanic/Latino   Other   Filipino

*Emergency Contact Name 

*Emergency Phone Number 

*Emergency Contact Relationship to Student (You) 

What is your educational goal?
Transfer without AA/AS   Transfer with AA/AS   Certificate   AA/AS Degree

(Write undecided if unsure of major.)

*Major: 

*Have you passed the California High School Exit Exam (CAHSEE)?  Yes   No

*Are you an emancipated foster youth and/or have been in foster care, kinship care or guardianship?  Yes   No

*Are you a parent?  Yes   No

*Do you have a disability that may require special accomodations to participate in this program?  Yes   No

If you have a disability, please explain in how we can accomodate you?

*Are you interested in applying for Extended Opportunity Program and Services (EOPS)  Yes   No

(If yes, a follow-up letter will be forwarded to you to determine eligibility.) *EOPS provides support services such as: counseling, priority registration, financial aid processing, tutors, book assistance, UC and CSU application fee waivers, workshops and award ceremonies. *Services subject to change based on funding.