Continuing Student Form
I authorize the ocials of Cerritos College to transmit informaon to any agency, company or person regarding my
academic progress and any other pernent educaonal data.
I agree to nofy the Cerritos CalWORKs Oce of any changes made during the semester aer compleng this Connuing
Student Form.
I agree to aend a CalWORKs Student Success EAP Orientaon, if I have not done so my rst semester at CalWORKs.
I understand that to be compliant with the CalWORKs program I must meet with a CalWORKs Counselor to update my
Educaonal Plan, submit a Work-In Progress (WIP) Form and Cash-Aid eligibility (Noce of Acon/Vericaon of Benets)
EVERY Semester.
I have submied or aached proof of Eligibility for this Semester.
Student Signature: _____________________________Date: _________
Personal Informaon: (SC06-10)
Name: ________________________________________________
Student #:____________ Phone Number: ___________________
Email: ________________________________________________
Current Home Address: __________________________________
City: ______________________________ Zip Code: ___________
Proof to Work in U.S.: Yes No
Primary Language: _____________________________________
Marital Status: Single Married
Separated Widow (er)
Unmarried, but living together
If marked “Unmarried, but living together” are you and your part-
ner on the same case? Yes No
Has the number of children changed since your last intake?
Yes No
If yes, new number of children under 18 years old: _________
Name: ________________________ Age:_____________
Name: ________________________ Age:_____________
Is your Childcare provider: On-Campus O-Campus
GAIN Informaon: (SC01)
Social Worker Name: __________________________________
4-Digit File Number: _________Case #: ___________________
Address: ____________________________________________
City: _________________________ Zip Code: ___________
Phone: ___________________ Fax: ______________________
Employment: (SC011-17)
Are you currently employed? Yes No
If yes, Name of Company or Employer:
____________________________________________________
Title or Job Descripon: ________________________________
Start Date: __________ Hours worked per-week: _________
Highest hourly wage $_________
Is this posion Volunteer? Yes No
Are you receiving college credit for this posion?
Yes No
Are you currently part of the CalWORKs Work-Study Program?
Yes No
Would you be interested in working on campus through our
CalWORKs work-study program?
Yes No
Resources: (SC02-5)
Are you currently part of any of these departments? (Check all that apply)
Financial Aid Financial Aid Work-Study
EOPS CARE
DSPS Health Center
Student Success Center Foster Care (LINC)
If you answered NO to any of the departments above, would you
like to receive more informaon from that department?
Yes N o
OFFICE USE ONLY
Date Received: ___________________ Semester Code: _________
Entered by: _________
Eligibility SARS PeopleSo
CW> INTAKE> CT STU IN-TAKE (5/23/16) BGAMEZ
