CalWORKs Program – Woodland Community College
Application and Orientation Form
Academic Year 2020-2021
Please complete the following information! You must be in good standing with your county welfare
office and be a current TANF/CalWORKs recipient.
Student Information:
Name: (last name, first name, middle initial)
Address: (Street Address, City, State, Zip)
Email Address:
Phone Number:
Date of Birth: (MM,DD,YYYY)
Gender:
Have you submitted a fee waiver for 2020-2021?
□ Yes □ No
Have you submitted a FAFSA for 2020-2021?
□ Yes □ No
County Eligibility:
Are you currently receiving county CalWORKs?
County Location: (Ex: Yolo, Colusa, Sacramento)
County Worker’s Name:
County Worker’s Phone Number:
Is education an approved Welfare-to-Work Activity?
□ Yes □ No
What is your county approved educational
goal?
List all members of your family receiving county aid, their relationship to you and their ages:
With my signature below, I acknowledge that I have carefully reviewed the content of this application and certify that the
information contained herein is true and complete to the best of my knowledge per penalty of perjury. I also realize that any
false statement or failure to give proof when asked may be cause for the denial, termination, and/or repayment of CalWORKs
services or equivalent cost for services. I authorize the sharing of information regarding this application between Woodland
Community College CalWORKs, the Yuba Community College District, the Chancellor’s Office of the California Community
Colleges and county social service agencies, as applicable. I understand that I can be removed from this program if I fail to
comply with program guidelines, county requirements, fail to progress academically, or at WCC CalWORKs discretion. Lastly,
I understand that services provided by this program are contingent upon available funds.
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signature
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