Fillable CalWORKs Program Application and Orientation Form (Sacramento City College)

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CalWORKs Program Application and Orientation Form (Sacramento City College)

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The CalWORKs Program Application and Orientation Form (Sacramento City College) form is 2 pages long and contains:

  • 1 signature
  • 26 check-boxes
  • 96 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Sacramento City College

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CalWORKs Program Application and Orientation Form
Page 1 of 3
☐American River College
☐Cosumnes River College
☐Folsom Lake College
☐Sacramento City College
SECTION 1 – STUDENT INFORMATION
Last Name, First Name, Middle Initial:
Student ID:
Academic Year:
Address:
City
E-mail Address (required): Primary Contact #:
Date of Birth (month/day/year):
Sex:
☐
Male
☐
Female
Have you submitted your current FAFSA?
☐
Yes
☐
No
Have you submitted a BOG Fee Waiver?
☐
Yes
☐
No
SECTION 2 – COUNTY ELIGIBILITY
County Worker’s Name:
County Worker’s Code:
County Case #:
Worker’s Phone Number:
Worker’s Office Location (i.e. County Office or
Bureau):
Are you currently receiving county CalWORKs?
☐
Yes
☐
No
Are you currently sanctioned by the county?
☐
Yes
☐
No
If yes, is there a cure in place:
List all members of your family receiving county aid, their
relationship to you and their ages (please note any non-
children):
Name (First and Last)
Relationship
Age
SECTION 3 – EDUCATIONAL GOALS
Is education an approved Welfare-to-Work Activity?
☐
Yes
☐
No
Have completed the college assessment?
☐
Yes
☐
No
What is your county approved educational goal?
☐Certificate
☐
AA/AS Degree
☐Inter-District Transfer (to ARC, CRC, or SCC)
☐Transfer to 4-year university
☐Improve Job Skills
If you have taken a Los Rios Assessment test within
the past
two years, please check those assessment
areas for which
you were assessed?
Math:
☐
English/ESL:
☐
Did Not Take:☐
/
/
Zip
State
✔
CalWORKs Program Application and Orientation Form
Page 2 of 3
☐American River College
☐Cosumnes River College
☐Folsom Lake College
☐Sacramento City College
SECTION 4 – CAMPUS SERVICES
EOPS
☐
Yes
☐
No
CARE
☐
Yes
☐
No
DSPS
☐
Yes
☐
No
Financial Aid ☐
Yes
☐
No
Tutoring Center ☐
Yes
☐
No
Other campus services you are involved with or would like
more information about:
In what areas would you like assistance? (check all that
apply)
☐Advocacy with County
☐Tutoring
☐School Supplies (books, supplies)
☐
Counseling (academic, career, personal)
☐
Transportation
☐Community Service Referrals
☐Child Care Referrals
☐Other:
SECTION 5 – CURRENT EMPLOYMENT INFORMATION
☐
☐
If you are currently not employed or are looking for
new
employment opportunities please complete the
following
information about CalWORKs job resources.
Specifically, are you interested in job search services,
which
include the following (check all that apply):
☐Job search assistance
☐Job skill assistance
☐Interview skill enrichment services
☐
Resume/Cover Letter writing services
☐
Job placement services
☐Other employment services
☐Job transition workshops and services
☐
Volunteer and internship positions search
☐On-Campus CalWORKs Work-Study
(doesn’t affect cash aid)
☐Off-Campus CalWORKs Work-Study
(doesn’t affect cash aid)
information within the last 2 years (must be completed):
Job title:
_________________
________________
Name
of employer:
____________________________
Description
of work:
Start date: End date:
Average
hours per week:
Highest
hourly wage earned:
If you are not currently working, would you like assistance with locating a work-study placement on or off-campus?
Yes
No
Please list current job skills:
SECTION 6 – CERTIFICATION AND AUTHORIZATION
(APPLICANT MUST READ AND SIGN BELOW TO BE ELIGIBLE)
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. If asked by any authorized
College CalWORKs official, I agree to provide proof of program eligibility, which may include a copy of my and/or
my children’s’
public assistance award documents. 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 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 the CalWORKs
programs’ discretion. Lastly, I understand that services provided by this
program are contingent upon available funds.
Student Signature Date
/
/
/
/
✔
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CalWORKs Program Application and Orientation Form (Sacramento City College)

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Completed 5 September 2020

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