_____________________________________________________________________________________________
____________________________________________________ _____________________________________________
C
DPSS & GAIN INFORMATION
Are you in the GAIN Program? YES NO If NO, are you Exempt? YES NO Exemption reason:__________
* NOTE: If you are exempt, you will need to provide proof of your exemption from GAIN participation.
How were you referred to PCC? _________________ Are your required activity hours 20/30/35? ___________
Other than school, what other GAIN approved activities will you participate in to meet your required hours?
(Domestic Violence, Mental health counseling, job club, work, community services, etc.)____________________
Name of GAIN Worker:________________________________ GAIN Office:_____________________________
GAIN Worker phone:__________________________________ GAIN Worker fax:_________________________
EMPLOYMENT INFORMATION
Are you currently working? _______ Start date: ___________ Hours per week: _____ Salary per hour: _______
Your employer: __________________________________ Job title: ____________________________________
Work type: ☐ Regular job ☐ Work-Study ☐ Volunteer job ☐ Internship/class credit only
Are you interested in a Work-Study job position?
☐ YES ☐ NO [Office use only - TOP Code: ____________________]
NEEDS ASSESSMENT
Have you completed the FAFSA to apply for financial aid? YES NO If not, why? __________________
What services will you need to help you be successful at Pasadena City College? (Mark all that apply)
☐ Study Skills ☐ Tutoring ☐ Testing for Learning Disabilities ☐ Computer Skills ☐ University Transfer
☐ Financial Aid ☐ Child Care ☐ Psychological/Counseling Services ☐ Health Services ☐ Mentoring Programs
☐ Student Organizations/clubs ☐ Other (be specific):________________________________________________________
Please let us know if you are faced with any of the following circumstances:
☐ Learning Disability ☐ Physical Disability ☐ Domestic Violence ☐ Depression/Mental Health ☐ Legal Problems
☐ Substance Use/Abuse ☐ Homeless/Displaced ☐ Other ____________________________________________________
Are you receiving any of the following PCC services? ☐ EOPS ☐ CARE Program ☐ DSPS ☐ PASS Program
STUDENT CONSENT TO OBTAIN & RELEASE INFORMATION
I authorize the Pasadena City College CalWORKs Program to obtain and disclose information about me regarding CalWORKs
eligibility, school enrollment/attendance, academic progress, assessment results, child care, work-study and other supportive
services to relevant service agencies, including the Department of Public Social Services, GAIN, Childcare Resource Referral and
other Welfare-to-Work partners, when necessary. I affirm that all the information that I have provided on this CalWORKs
application is correct.
Student’s Signature Date
AL
S
FFICE
SE
NLY
☐ VOB/NOA Submitted ☐ Checked for TOP Code [ENTERED IN:
BANNER
EXCEL]
GAIN Status:
☐ SIP GN6005A ☐ Self-Referred ☐ VOC GN6006 ☐ Exempt ☐ Post-Employment
☐
Proof of Exemption End date_____ Reason___________________________________________
5HY
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