Laamt Application 2

Los Angeles Academy of MEDIA & TECHNOLOGY Another YOUTHBUILD Charter School

Cornerstone Baptist Church Site 5946 So. Figueroa, L.A. 90003 Administrator, Dr. Steve Jefferson 310-408-3478 Director, Bettye Sweet, M.S. 323-708-4156

^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ ^

Call o ne of th e a bove num ber s f or pi ck-u p o f com plet ed applic ation s PLEA SE TYP E or PRIN T

Last Name__________________________First Name________________________Middle Initial_______ Social Security #_____________________ Birth date ______/______/______ Age _____ Home Address_____________________________City____________State___________Zip Code_______ Telephone (____)_______________ Message/Cell Phone (____)_____________ Emergency Contact Info: Name___________________________ Phone_________Relationship________ Edu ca ti on Sta tus

Are you currently attending school? Yes___ No__ If yes, name of school?___________________________ Did you receive your HS diploma or GED? Yes____ No______ Highest grade completed?_____________ Educational Objective____________________ Career Objective__________________________________ T he f ollo win g a ns wer s wil l b e us ed f or as se ssm ent pur pose s o nl y. An swer s mar ked “ Yes” will not dis qu alify a n a pplic ant. Pl ea se ans wer ALL que stion s.

Are you a United States Citizen? Yes____ No____ If no, what is your Alien Registration Number?__________ Do you have any disabilities? Yes___ No___ If yes, please specify___________________________________ Do you have health insurance? Yes____ No____ Do you have a history of substance abuse? Yes____ No____ Are you currently using drugs or alcohol? Yes____ No____ If yes, please specify last date of use___________ Have you ever been convicted of a felony?Yes___No___ Are you currently on probation or parole?Yes__ No__ If yes, what is the name and number of probation or parole officer?____________________________________ Do y ou ha ve an y of the f ollo win g typ es of id entific atio n? (Ch ec k all th at a ppl y)

CA Driver’s License_______California ID__________Naturalization Papers___________ US Passport_______ Social Security________________ Birth Certificate____Medi-Cal Card_____ Other, please specify_________ Famil y St atus: (Ple as e c he ck the one s th at a ppl y to y ou)

Are you married? Yes___No___Do you have any children? Yes___ No ___If so, how many? Are you pregnant? Yes___ No___ Single Parent Household with Dependents under 18: Female___ Male_______ Two-Parent Household with Dependents under 18_____ Single with no Children ___ Female___ Male___ # Adults in Household___ #Children in Household______ Hous eh old In co me (Plea se c hec k all th at a ppl y to y ou)

ANFC/ANF_____ SSI___ GR___ Disability ______Social Security ____ Food Stamps ___Unemployment ___ Employment/Working___ Self-employed ___ Other ___ Please specify_____________________________ What’s your yearly income?_______________ Eth nicity/Ra ce ( Ch ec k On e)

African-American ___ Asian ___ Caucasian ___ Cambodian ___ Hispanic ___ Japanese ___ Korean ____ Native American ___ Filipino ___ Samoan ___ Chinese ___ Laotian ___ Vietnamese ___ Hawaiian ___ Puerto Rican ___ African ___ Other, please specify __________________________ Ho usin g St atu s (Che ck One)

Homeless ___ Live with parents ___ Live with friend ___ Live in group home ___ Live in a foster home ___ Live with relatives ___ Live alone ___ Live in a shelter ___ Live in a work release program ___ Ho w di d y ou fin d o ut a bout LAAMT/Y out hBuild?

Friends/Relatives ___ Parole Officer ___ TV/Radio ___ Other Youth Program ___ Shelter ___ Newspaper ___ Flyers/Posters ___ Neighbors ___ Community Organization/Church ___ Other, please specify ______________ For Of fice Use Onl y

Arrange interview Yes___ No___

Enrolled Yes ___ No ___ Remarks:

Date enrolled______________________________