NAME: STUDENT ID:
ADDRESS: PHONE NUMBER:
YUBA COLLEGE EMAIL:
City State Zip
CALIFORNIA RESIDENT: Yes No GENDER: Male Female
ETHNIC BACKGROUND: DATE OF BIRTH: AGE:
STUDENT PRIMARY LANGUAGE(S):_ PARENT/GUARDIAN PRIMARY LANGUAGE(S):___________________
FAMILY SIZE (include yourself): _______ PREVIOUS YEAR FAMILY INCOME (estimated): $ _____________
Are you a single parent? Yes No
1. Did either of your parents complete a Bachelor’s Degree or higher: Yes No
2. Previous Education: High School graduate Yes No Name of HS Dreamer Yes No
GED/HS equivalent Yes No Foster Youth Yes No
CalWORKs Yes No
3. What is your major, program of study? (required)
4. Educational Goal (check one below):
a) Transfer without AA/AS Degree c) AA/AS Degree e) Certificate/License
b) Transfer with AA/AS Degree d) AA-T/AS-T f) Basic Skills/Job Skills
(Degree for Transfer)
5. Have you completed a Guided Self-Placement for Math and English? Yes No
6. Did you transfer from another college/university? Yes No If yes, which one: ___________________________
7. Do you have any disabilities? Yes No If yes, please check all which may apply to you
Vision Hearing Learning Physical Other
8. How did you hear about the EOPS Program? _________________________________________________________
9. Please make a brief statement about yourself. Indicate your educational goals and objectives, what type of work you
would like to be doing five (5) years from now and let us know if you plan to work while attending Yuba College.
SIGNATURE DATE
***SPECIALIST USE ONLY***
Ed Dis Current Units 70 units or less Other (CARE/DSPS/DREAMER/FOSTER YOUTH)
Income ___ Family _____ BOG _________ EFC _______________________
Eligible/Not Eligible ______ ________________ Specialist __________ Date Reviewed
COMMENTS
CONTACTS Intake Date/Time
FRONT OFFICE USE ONLY (Form Revised April 2020)
Application Received Date Y-Drive Entered Date Date to Specialist
Emailed/Contacted Date Emailed/Contacted Date Emailed/Contacted Date
ALL INFORMATION must be completed in order for your application
to be reviewed and/or considered.
Submit completed application via email: YCEOPS@yccd.edu; in person or by mail to:
Yuba College 2088 North Beale Road, Marysville, CA 95901 Attn: EOPS/CARE Program
For more information you can visit our website: http://yc.yccd.edu/student/EOPS/default.aspx
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