Fillable Form 1: 1. CalWORKs Applicaon (Folsom Lake College)

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Form 1: 1. CalWORKs Applicaon (Folsom Lake College)

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1. CalWORKs Applicaon
2.
Aid Verification
3. Student Educaonal Plan
4. Class Schedule
1. FLC CALWORKS APPLICATION – To be completed by the student.
2. FLC AID VERIFICATION FORM – To be completed by your county worker. A
new Aid Verification Form will be due each semester and must be completed
during the following dates: SUMMER — JUNE 1 or later
FALL — AUGUST 1 or later
SPRING — JANUARY 1 or later
3. CALWORKS STUDENT EDUCATIONAL PLAN – To be completed with an FLC
academic counselor. Visit the Counseling Department to schedule a 30-minute
appointment with a counselor to create a 1-semester CalWORKs specific
Student Educational Plan that will meet your county Welfare-to-Work
requirements.
>> A comprehensive Student Educational Plan will be created by a
CalWORKs counselor (once you’ve been admitted into the
CalWORKs program) and will cover 4-6 semesters of academic
course planning.
Be sure to bring your Math & English Assessment results and all
college transcripts (unofficial are acceptable) to your initial counseling
appointment to ensure correct course assignment.
4. CLASS SCHEDULE – Print your class schedule from your eServices account.
Register in at least one FLC, EDC, or RCC class from your current Student
Educational Plan.
STEP 1 – APPLICATION CHECKLIST You may pick-up the FLC CalWORKs Application and TANF
Verification Form from our office, or print them online: www.flc.losrios.edu, select CalWORKs (under the Quick
Links drop down menu), and click on Forms and Resources.
1
Your Class Schedule and Student Educational Plan must match. If you
added classes that are not on your Student Educational Plan, you will
need to meet with a counselor once again to have it updated.
Counselors will not be able to simply “add classes to your Student
Educational Plan.” Rather, they will review your file (transcript/major)
and update your Student Educational Plan based on the requirements
towards your goal and maintaining your county compliance. Often
times it is not a “quick process” so please plan ahead.
NOTE!
STEP 2 – FLC CALWORKS ORIENTATION
Please call the FLC CalWORKs office to schedule a program orientation appointment. You will need to bring all 4
items listed above to your orientation.
2
IMPORTANT! If you have changed your class schedule and it no longer
matches your Student Educational Plan, we will have to re-schedule your
CalWORKs orientation appointment. See number 4 above.
During your orientation, we will:
Complete your Textbook Verification Packet
Review your documents and eligibility, note your assessment results and
their meaning.
Discuss your academic schedule and county requirements to ensure you
are in compliance.
Provide you with program information and answer any questions you
might have about the services, support, advocacy, and coordination that
our program can offer you on your pathway to success, lifelong self-
sufficiency and empowerment.
My CalWORKs Orientation Appointment:
Date Time
Location CalWORKs Staff
Required Items:
□ CalWORKs Application
□ Aid Verification Form
□ Student Educational Plan
□ Class Schedule
Revised July 2016 FOLSOM LAKE COLLEGE • CALWORKS • LOS RIOS COMMUNITY COLLEGE DISTRICT
Counseling Office:
Folsom Lake College FLC 916-608-6510
El Dorado Center EDC 530-642-5645
College Bookstore:
FLC 916-608-6565
Rancho Cordova Center
CalWORKs Office:
FLC 916-608-6560
EDC 530-642-5648
RCC 916-361-6305 RCC 916-361-6321
☐American River College
☐Cosumnes River College
☐Folsom Lake College
☐Sacramento City College
Textbook Verification Form Process
1.
A Textbook Verification Packet -also known as a Book Request- will be completed by your
CalWORKs Advisor during your New or Continuing Student Orientation appointment. Your packet
will incl
ude the following:
Current class schedule- classes must match your Student Education Plan
Booklist- provided f
rom your course syllabi or from your college bookstore
Current Student Education Plan (SEP)- created by a CalWORKs Counselor
Current Unofficial Transcripts- must show your grades and G.P.A. for the previous semester
2.
This form and all attached documents must be complet
ed with a C
alWORKs
s
taff
me
mber to verify the
total cost of books. A CalWORKs staff member must sign this form in order for your County DHA worker
to approve and issue a check for your books. You will receive a copy and a copy will also be sent to your
worker who will then process the request.
3.
Once sent, it is the students responsibility to follow up with their worker to find out if the
Textbook Verification Packet was approved.
Please allow a Two-Day turn around for our verification process
Information Included on the Textbook Verification Form
You must be enrolled in the classes for which we are submitting
a request for books- not
waitlisted.
The classes you are enrolled in must be listed on your Student Ed Plan, created by a CalWORKs
or General Counselor
If you are enrolled in some classes and waitlisted on others, we will submit a textbook
verification form for the classes in which you are enrolled. If and when you have enrolled
in the waitlisted class and it shows you are enrolled we can then complete a separate
textbook verification form for that class.
If you are enrolled in classes at another Los Rios college in the same semester, please talk to
your CalWORKs a
dvisor about how supportive services will be provided to you.
We only list the required books; we do not include the recommended books.
We put down NEW book prices, never a used book or rental price.
4.
Depending on your county and specific case, it may take several weeks for you to hear back. We
recommend you follow-up with your worker approximately 1 week after they’ve received your Textbook
Verification Packet.
5. If approved, your worker will give you information on how to go about obtaining your books.
✔
CalWORKs Program Application and Orientation Form
Page 1
☐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
☐American River College
☐Cosumnes River College
☐Folsom Lake College
☐Sacramento City College
SECTION 4 – CAMPUS SERVICES
Are you currently receiving services from?
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
Are you currently employed?
☐
Yes
☐
No
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)
Please note below your current or your most recent job
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 your job or career goal:
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
/
/
/
/
✔
click to sign
signature
click to edit
CalWORKs Program Aid Verification Form
Thank you for your consideration and time in completing this document for our common student.
Please contact the respective CalWORKs office if you have any questions regarding this request.
☐American River College
☐Sacramento City College
☐Folsom Lake College
☐Sacramento City College
SECTION 1 – STUDENT INFORMATION (to be completed by the student)
Last Name, First Name:
Student ID #:
Last 4 of Social Security #:
The information requested below is specifically for the current time period.
SECTION 2 – STUDENT CASE ELIGIBILTIY (Must be completed by respective county representative.)
1. Is the student a current recipient of cash aid via the county’s
CalWORKs program?
☐
Yes
☐
No Date Services Started: __/___/___
2. Is this school an approved Welfare-to-
Work activity for this student?
☐
Yes
☐
No
3. a) What are the total number of dependent children on the
student’s case who are currently receiving cash aid?
_____________________________________________
b) Does the student have at least one dependent child who is 13 years old or younger? ☐
Yes
☐
No
4. Is the student defined as single, head of household?
☐
Yes
☐
No
5. Student’s current legal marital status:
☐
Married
☐
Single
☐
Divorced
☐
Separated
6. a) What is the student’s current CalWORKs eligibility status?
☐Aided ☐Sanctioned ☐Timed Out (Date: __/___/___) ☐Discontinued from Aid (Date: __/___/___) ☐Other
If the student is currently in sanction status is education approved to cure their sanction?
☐
Yes
☐
No
b) If “Aided” or “Other,” please select the most appropriate status below (please see reverse side for standard
definitions of these terms):
☐County Referred ☐Se
lf-Initiated (SIP) ☐Voluntary Exempt ☐Exempt (other) ☐Post-Employment
7. Are there any other adults on the case that are eligible for
CalWORKs services (spouse, partner, etc.)?
☐
Yes
☐
No
8. If the student completes the process, is the student eligible to receive childcare through the county?
☐
Yes
☐
No
9. If the student submits all school verification for the current semester, will the county cover costs for the following:
Text books:
☐
Yes
☐
No Supplies:
☐
Yes
☐
No Transportation:
☐
Yes
☐
No Other ___________:
☐
Yes
☐
No
10. a) Please indicate if the student is utilizing the CalWORKs Minimum Standards or CalWORKs Federal Standards, and
how many month(s) are remaining on the CalWORKs 48-Month Time Clock.
☐CW Minimum Standards ☐CW Federal Standards Months Remaining: ___________
b) What is the student’s/family’s WTW participation hours requirement?_______________
If the answer is NO to questions 1, 2, & 6 (not aided or sanctioned), no CalWORKs services can be rendered.
Name of Agency:
Must be stamped by
county to be valid.
Fall 2018
COUNTY STAMP HERE
Student County Case Number:
Agency Representative/Worker Name:
Agency Representative Telephone:
Agency Representative/Worker Signature
Date:
/ /
(Not valid without signature and county stamp.)
(Not valid for current semester, if dated before the
start of the semester.)
American River College
Ph: 916-484-8059
Fax: 916-484-8573 Attn:
ARC CalWORKs
Sacramento City College
Ph: 916-558-2331
Fax: 916-558-2169 Attn: SCC CalWORKs
Cosumnes River College
Ph: 916-691-7465
Fax: 916-691-7434 Attn: CRC CalWORKs
Folsom Lake College
El Dorado Center
Ph: 530-642-5620
Fax: 916-608-6637 Attn: CalWORKs
Folsom Main Campus
Ph: 916-608-6560
Fax: 916-608-6637 Attn: CalWORKs
Rancho Cordova Center
Ph: 916-361-6305
Fax: 916-608-6637 Attn: CalWORKs
✔
XXX-XX-_____
✔
2019
CalWORKs Program Aid Verification Form
☐
American River College
☐ Cosumnes River College
☐ Folsom Lake College
☐ Sacramento City College
Guidelines for CalWORKs Eligibility Verification Form Completion
1. No CalWORKs services can be provided without a current CalWORKs Eligibility Verification form on file.
2. This form must be completed each semester by all CalWORKs students (one form per student).
3. This form must be signed and stamped in the same month for which services are sought – services cannot be
provided retroactively.
4. Please make sure questions 1-10 are answered as complete as possible by your county worker/representative
before turning in this document – NO INCOMPLETE DOCUMENTS WILL BE ACCEPTED.
5. All documents require both a county worker/representative signature and county stamp/seal to be valid.
Receipt of this document by the CalWORKs office does not guarantee that services or support will be provided, as all
services and support are provided per funding and the director’s discretion.
CalWORKs Student Eligibility Definitions
County Referred Participant:
This designation applies if the student is a CalWORKs/cash aid recipient, has at least one eligible child and was referred
to the community college by the county welfare office and has an approved Welfare-to-Work (WTW) plan or is in the
process of developing a WTW plan.
Self-Initiated Participant (SIP):
This designation applies if the student is a CalWORKs/cash aid recipient, has at least one eligible child and is attending
the community college as a Self-Initiated Participant (SIP) and is or will be in the process of obtaining an approved
WTW plan through their county welfare office. Refer to the California Department of Social Services All County Letter
99-32 for additional information on SIP criteria.
Voluntary Exempt:
This designation applies if the student is a CalWORKs/cash aid recipient, has at least one eligible child but has been
exempted from participating in WTW activities by the county for a reason enumerated with an All County Letter or All
County Information Notice.
Exempt Student (other):
This designation applies if the student is a CalWORKs/cash aid recipient, has at least one eligible child but has been
exempted from participating in WTW activities. The college must have documentation in the student’s file proving the
student’s exempt status and when the exemption will expire.
Post-Employment Participant:
This designation applies if the student is off cash assistance due to unsubsidized employment and is in compliance
with their county welfare office. This would be a former CALWORKs/cash aid recipient who has completed their WTW
plan or SIP and is employed but desires additional training. A student in this status cannot be one that is sanctioned by
the county welfare office for not adhering to their WTW plan. The college must verify student employment at the
beginning of each term.
If your student/customer does not fall into County Referred or SIP categories, please detail the student’s situation per
Question 6b on the reverse side of this document or contact the respective CalWORKs office at the numbers provided.
✔
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Completed 4 September 2020

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