Form

Interested in becoming a student? Let us know so we can keep in touch!

First name*

Last name*

Email*

Phone number*

Date of birth *

Please enter in XX/XX/XXXX format

Have ever applied to a PCCD college (College of Alameda, Berkeley City College, Merritt College, or Laney College)*

Yes

No

Are you interested in receiving information on programs and services for students with disabilities?*

Yes

No

Are you interested in learning about any of the following? *

Programs and services for Latinx students

Programs and services for African American students

Services for Military Veterans/Dependents of Veterans

Programs and services for Foster Youth

Programs and services for low-income, first-generation college students

Programs for students interested in Science, Technology, Engineering, and Math

None

Are you a High School Senior?*

Yes

No