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Application

Student Name:
Preferred Communication:
Birthday:

Parent or Guardian Information

Parent/Guardian Name:

Mailing Address

Address

Demographics (optional)

Ethnicity:
Siblings? (names and ages):

School Information

Name of Reference:
Are you in the first generation in your family to attend college?

Please Save the Date

- Students must attend a Student Orientation in December 2019
- Parents/Guardians must attend a Parent/Guardian Orientation in December 2019

Health Information:

Select your level of fitness:
Select your swimming ability:
Sharing conditions will not necessarily affect your acceptance into the program, but will allow us to provide additional support if needed. All information is kept confidential.
Have you been treated by a physician or taken any prescription medications in the last 2 years?
(* Parent/Guardian – Signing this application indicates you support your child’s application to participate and have read the application form and the accompanying information.)

Personal Questionnaire

Please answer on a separate sheet. Print neatly or type so we can read your answers easily. This is your opportunity to help us get to know you. Be thoughtful and complete in your answers.
***APPLICATION DEADLINE OCTOBER 15, 2021***

Serving Santa Barbara Community Members since 1994

Dr. Hollanda Leon, MD

Family Practice Physician

Meet the Providers