1. education
2. graduate school
3. college

Tribal Learning Community & Educational Exchange
TLCEE Honors/Leaders Application
This application is for the Tribal Learning Community & Educational Exchange (TLCEE) “Leaders” program and will be used for administrative
purposes. Though exceptions may be made, application should be for currently enrolled high school students, grade 9-12. All applications must be
completed to be enrolled in our program, with Parent or Legal guardian permission. This application will be held and kept by the TLCEE and our
University partnered programs and will be kept confidential.
1. Name: _____________________________________________________________________________________
2. Address: ___________________________________________________________________________________
3. City: ___________________________________________________ 4. Zip Code: ________________________
5. Home Phone Number (Please include Area Code): _________________________________________________
6. Email Address: _______________________________________________________________________________
7. Tribal Affiliation: ________________________ 8. High School Attending: _______________________________
9. Age: ________ 10. Date of Birth: ___________
12. Current Year in School (Check One)
11.
Senior
Male
Junior
Female
Sophomore
Freshman
Other: ___________________________________________
13. What is your current school schedule (Date/Semester/Quarter): ______________________________________
1. _________________________________
2. ________________________________
3. _________________________________
4. ________________________________
5. _________________________________
6. ________________________________
14. What are your most difficult subjects?: __________________________________________________________
15. (Optional) Overall Projected GPA : ___________
Name: ______________________
Student Information-Application
Student Information (Please Print)
Parent or Legal Guardian Information
Name of Parents or Legal Guardian: ___________________________________________________________________________
Address: __________________________________________________________________________________________________
City: _________________________________________________ State: ________________________ Zip Code: _____________
Primary Contact Number: ______________________________ Secondary Number: ____________________________________
Email Address: _____________________________________________________________________________________________
In case of emergency, we will contact the Primary contact number and then the secondary number (in that order). Are there any
other numbers and persons whom you will want us to contact beyond those numbers?: ________________________________
_________________________________________________________________________________________________________
Contact the TLCEE Program at our
Email address:
[email protected]
The TLCEE Program does not discriminate based on sex, sexual orientation, color of skin, religious
background, nor ethnic background. The TLCEE Program the University of California policy against
discrimination is funded through public and private donations and grants.
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Tribal Learning Community & Educational Exchange
TLCEE Honors/Leaders Application P2
16. Are you participating in any other programs or after-school activities? If yes, please list:
Yes
No
16a. ________________________________________________________________________________________________________
17. What are your thoughts on College? ___________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
18. Are currently taking College Prepatory courses in High School? If yes, please list:
Yes
No
18a. ________________________________________________________________________________________________________
____________________________________________________________________________________________________________
19. Have you discussed College requirements with a counselor, teacher or family members/etc? :
Yes
No
19a. If so, do you feel you have enough knowledge to pursue higher education? Select one below:
I have enough knowledge
I have some knowledge
I need more knowledge
I have no knowledge
____________________________________________________________________________________________________________
20. Has anyone in your immediate family ever attended college?
Yes
No
20a. If so, did they graduate from college and what is their relation to you? _____________________________________________
21. Have you taken the PSAT/SAT/ACT?
Yes
No
21a. If any please list: ____________________________________
Please tell us about yourself. Include what your interests are and why; (ie: what your favorite subjects are and why; what you like
in hobbies or after school activities and why, or anything that may say something about yourself ). Use additional paper if needed.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
All questions above will be kept confidential and used for administrative purpose. These questions will help our program to better
assist you in preparing personal statements, developing academic workshops to prepare our student for higher education and to
help us develop a stronger program by knowing our client background.
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Tribal Learning Community & Educational Exchange
TLCEE Honors/Leaders Application
PARENTAL/GUARDIAN CONSENT AND RELEASE OF INFORMATION
We, the parent or guardian of (student’s name): _________________________________________ permit our son/daughter/ or
registered student, to attend the TLCEE Leaders Class at our partnered program’s educational centers, being planned by the TLCEE
Program in accordance with our posted schedule. The purpose of this program is to academically prepare our Native youth for
higher education through our for-credit college program. By signing this form you understand that:
A. the high school students who will enroll in this program will receive an academic grade that will be on their academic
transcripts when submitting to the university system (universities that they may apply to).
B. the high school student will be required to attend one session on the UCLA Campus, on a Saturday during the academic
quarter.
C. Are required to complete a set amount of hours in course reading and participation as required under the university
guidelines.
We, as parents/guardians of the undersigned minor(s), hereby consent and agree to hold harmless, the TLCEE Program, and any
and all employees or volunteers thereof, for any accident, injury or occurrence arising out of, or in connection with the activity and
our child's event arranged transportation necessary to participate in any aforementioned activities and class. We understand that
where transportation of the student occurs, the student, will be assigned to ride with a licensed adult driver, driving a privatelyowned automobile, or bus and that this assignment will be made by the aforementioned partnered Tribal Education Center, as
applicable. Initial: _________
Photographs and video will be taken within our program and the Applicant and Parent /Legal Guardian gives their consent signing
to allow these images to be taken. By signing this application, the Applicant and Parent /Legal Guardian gives their consent to the
TLCEE Program to use such materials within the scope of the program for present and future use. Initial: _________
This application is not complete without signature of your Parent or Legal Guardian, giving their permission for you, the applicant,
to attend our “Leaders” program. The TLCEE Program reserves the right to materials developed within the program itself,
including research, video and photos for further use. By signing this application, the Applicant and Parent/Legal Guardian
understands the nature of this program and the current schedule and allows applicant to participate within those activities. All
applicants will adhere to TLCEE Programs Rules/Guidelines.
Signature of Applicant: ______________________________________________________________ Date: _____________________
Signature of Parent or Legal Guardian: __________________________________________________ Date: _____________________
Emergency Medical Treatment: In the event of an emergency, I hereby give permission to the TLCEE Program, it's officers, directors
and agents, and representatives, volunteers and employees of either our partnered agencies (example: Tribal Educational Centers)
and chaperones or representatives associated with this event to transport my child to a hospital for emergency medical or surgical
treatment. I understand that every effort will be made to contact me. If I cannot be reached, I hereby give permission to the
physician selected by the TLCEE Program member in charge or adult chaperone(s) to secure proper treatment for my
son/daughter.
Parent/Guardian Signature: _________________________________________
Date: ______________
Tribal Learning Community & Educational Exchange (TLCEE)
385 Charles E. Young Drive East, 1242 Law Building,
Los Angeles, CA 90095
Office: 310-794-5216
[email protected]
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