Important Note: All Paper Work Requests Have a 10-day Turn-around Period
Revised 7/25/2014 1570 East Colorado Blvd. D-204 • Pasadena, CA 91106-2003 • (626) 585-7808 • FAX (626) 585-3268
ASSIGNED GUARDIAN STATEMENT
The following authorization form must be completed by a parent of the applicant if the applicant is under the age of 18. A
completed form and a copy of the U.S. guardians California driver’s license/identification card must be on the file in the International
Student Center before the student will admitted for the term applying (U.S. guardian address must match information below).
Pasadena City College (PCC) International Student Center (ISC) requires that students who are under the age of 18 have a guardian
over the age of 21 living within 75 miles of Pasadena City College. In the event of a personal emergency, accident, illness or
incarceration, the State of California will require the signature of a guardian before offering assistance such as hospitalization or
legal counsel. Pasadena City College is not permitted to act in place of the parent or guardian. If you are under the age of 18, you are
required to have your parent submit a signed statement informing Pasadena City College who will be assigned as your guardian.
I, ____________________________________, the parent of __________________________________, am giving
(Parent’s Name: Last, First) (Student’s Name: Last, First)
permission to ______________________________________ to be the legal guardian of __________________________
(U.S. Guardian’s Name: Last, First) (Student’s Name: Last, First)
while he/she is studying at Pasadena City College. In case of any emergency, accidents, or illness, please contact:
Name of U.S. Guardian: __________________________ Guardian Date of Birth: ____/____/______ Age: ______
Relationship to Student (i.e. Aunt, Brother, Family Friend): ___________________________________
Address: ______________________________________________________________________
House Number Street Apt #
___________________________ California ___________________
City State Postal Code
Home Phone: (_____) _________-___________ Cell Phone: (_____) _________-__________
E-mail Address: _________________________________________________________________
I understand that Pasadena City College strongly recommends that minor students live either with family or family friends or under the supervision
of a host family until they turn 18. I UNDERSTAND THAT THE COLLEGE HAS NO LEGAL RESPONSIBILITY FOR THE CARE OR WELL BEING OF THE
MINOR STUDENT WHEREVER HE OR SHE CHOOSES TO LIVE WHILE IN THE U.S. ATTENDING PASADENA CITY COLLEGE. I ALSO UNDERSTAND THAT
THE COLLEGE HAS NO RELATIONSHIP WITH ANY HOMESTAY COMPANY AND ASSUMES NO RESPONSIBILITY FOR THE ACTIONS OF ANY HOST
FAMILY OR HOMESTAY COMPANY.
A copy of the guardians California driver’s license must accompany the form, the address must match information above otherwise form will not be
accepted. If the guardian cannot abide by this requirement, the student will not be admitted for the term applying.
