Continuing Student Form
I authorize the ocials of Cerritos College to transmit informaon to any agency, company or person regarding my
academic progress and any other pernent educaonal data.
I agree to nofy the Cerritos CalWORKs Oce of any changes made during the semester aer compleng this Connuing
Student Form.
I agree to aend a CalWORKs Student Success EAP Orientaon, 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
Educaonal Plan, submit a Work-In Progress (WIP) Form and Cash-Aid eligibility (Noce of Acon/Vericaon of Benets)
EVERY Semester.
I have submied or aached proof of Eligibility for this Semester.
Student Signature: _____________________________Date: _________
Personal Informaon: (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 togetherare 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 Informaon: (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 Descripon: ________________________________
Start Date: __________ Hours worked per-week: _________
Highest hourly wage $_________
Is this posion Volunteer? Yes No
Are you receiving college credit for this posion?
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
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 informaon from that department?
Yes N o
Date Received: ___________________ Semester Code: _________
Entered by: _________
Eligibility SARS PeopleSo