This application is for the summer of 2019. Submitting an application for any of the the Heart of Los Angeles programs does not guarantee admission into those programs. Furthermore, some programs may require additional information and document submittal to complete the enrollment process.

Esta solicitud es para el verano de 2019. Completando esta solicitud no le garantiza cupo en los programas de HOLA. Algunos programas requieren informacion y documentos adicionales.

Participant Information/Informacion del Estudiante

Additional Student Information/Informacion Adicional

Medical Conditions/Allergies (If any)/Condiciones Medicas/Alergias: *

None/Ninguno

Other/Otros: Other/Otros:

IEP(Individual Education Plan)/Special Learning Needs / IEP(Plan Especial Educativo)/Necesidades de Aprendizaje: *

No/No

Yes/Si Yes/Si

Household / Adult Primary Contact/Contacto del Adulto Principal

Relationship to Participant/Relación al Estudiante: *

Mother/Madre

Father/Padre

Guardian/Tutor Legal

Other/Otro Other/Otro

Household / Adult Secondary Contact/Contacto del Adulto Secundario

Relationship to Participant/Relación al Estudiante: *

Emergency Contact Info/Contacto de Emergencia

Authorized Pickup/Personas Autorizadas

Student has permission to walk home from Heart of Los Angeles/El estudiante tiene permiso a caminar a la casa solo. *

Yes/Sí