Student Life and Services Office
3041 West Avenue K • Lancaster, CA 93536-5426 • (661) 722-6300 Ext. 6354
Student Representation Fee Waiver
The Student Representation Fee of $2.00 will provide support for students or representatives who stand for
student positions and viewpoints before city, county, district governments, offices and agencies of the state
and federal government.
You may opt out of paying the Student Representations Fee.
Form must be submitted prior to registration of the upcoming semester, and takes up to 48 hours to process.
Please complete this form and email to firstname.lastname@example.org.
Applicant Name Printed
Applicant Signature (re-type full name)
Parent or Guardian* (see note below) Applicant Student ID #
Applicant’s Official AVC Email Address (required) Summer
Street Address City, State, Zip Code
_______ / _______ / ________ ( ) -
Date of Birth Phone Number
*Note: If applicant is 18 years of age or over, signature of parent or guardian is not necessary.
FOR OFFICE USE ONLY