Date of Birth
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Street Address (Example: 123 Main Street)
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Apt/Unit #
City
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State
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Zip Code
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Race (check all that apply)
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American Indian or Alaska Native
Black or African American
Central Asian (e.g., Uzbek, Kazakh, Afghan)
East Asian (e.g., Chinese, Japanese, Korean)
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
South Asian (e.g., Indian, Pakistani, Bangladeshi, Sri Lankan)
Southeast Asian (e.g., Filipino, Vietnamese, Cambodian, Hmong, Thai)
Two or more races
White
How many people are currently living in your household (including yourself)?
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Estimated Annual Household Income
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$10,000 to $19,999
$100,000 to $149,999
$150,000 or more
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $89,999
$90,000 to $99,999
Less than $10,000
What is your major? (If not enrolled, write n/a)
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Have you ever attended a community college: If other, please specify
What year do you expect to graduate? (If not enrolled, type n/a)
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If yes — please list the programs or placements you received through LA-Tech.org:
If you heard about LA-Tech.org through a friend, please type their first and last name:
If you heard about LATech.org through a staff member, please type their first and last name:
If other, how did you hear about us?
Questions or notes about program commitment:
Short Answer #1) What interests you about this selected pathway and the LA Tech Rising Internship Program? How do you hope this experience will support your career goals?
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Short Answer #2) Describe a time you worked on a team. What was a challenge you faced, how did you communicate with others, and what did you learn about collaboration?
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Short Answer #3) This program requires consistent participation in live sessions and professional development activities. How do you stay organized and show up for your commitments?
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