Grays Harbor College (GHC)
Workforce Funding and Support Programs Application
Legal Last Name: ______________________________ Legal First Name: _______________________________
Preferred Name: _________________________________ Student ID #: __________-__________-__________
Mailing Address: _____________________________________________________________________________
(Number & Street)
(City) (State) (Zip)
Phone: (_____)_______________________________ Date of Birth: ______/_______/________
Email*: Are you a veteran? Yes No
Have you been a Washington State resident for at least one year? Yes No
Are you currently receiving services from any of the following? Please check all that apply:
TANF Basic Food Assistance Unemployment Social Security Benefits N/A
Are you seeking an Early Achievers Grant to pursue an Early Childhood Education certification to maintain your
current employment? Yes No
Total monthly household income: $________________ Number of People in Household: ________________
Persons in Household 200% Poverty Guidelines
200% Poverty Guidelines
1 $25,520 $2,126
2 $34,480 $2,873
3 $43,440 $3,620
4 $52,400 $4,366
5 $61,360 $5,113
6 $70,320 $5,860
7 $79,280 $6,606
8 $88,240 $7,353
Add $4,320 for each person over 8 $ 4,480 $ 360
Please indicate which certificate, degree or pre-college program you are pursuing at GHC and the quarter you will be starting:
Accounting * Automotive *
Business Management * Business Technology *
* Criminal Justice *
Commercial Tra
nsportation and Maintenance
Technology *
Early Childhood Education *
Services * Medical
Assistant *
Welding Medical Office Administrative Support *
Nursing * Natural Resources* Occupational Entrepreneurship Transitions Programs: High School 21
* GED * English Language
Acquisition (ELA)
*(Please download this document to your device and open it from there otherwise the application will not save the text you have entered)*
Grays Harbor College (GHC)
Workforce Funding and Support Programs Application
What is your program expected end date? Month_________ Year________
Are you a currently a registered GHC student? Yes No
Have you completed a college degree or certificate? Yes No
College degree or certification(s) obtained _____________________________________________________
Current Employment: Part-time Full-Time None
Current Employer: ___________________________________________________________________________
Hours per week: __________________________ Wage per hour $: ____________________________________
Employer of last job held ___________________________________ Position: ___________________________
Have you received unemployment benefits within the last 48 months? Yes No
Have you been terminated, laid off, or received “notice of termination or layoff” and are unlikely to return to your
usual occupation or industry? Yes No
Were you self-employed within the last 24 months? Yes No
Have you applied for Financial Aid? Yes No
Which of the following is most likely to prevent you from being successful at school: Please check all that apply:
Lack of tuition funding Lack of textbooks Lack of Childcare Lack of Housing
Please tell us about why you are seeking our support at this time:
GHC staff adheres to Family Educational Rights and Privacy Act (FERPA) regulations regarding the privacy of
student information. The information you give us is confidential. Your signature certifies that the information you
provided is to the best of your knowledge. It also authorizes GHC staff to share information.
Student Signature: _________________________________________ Date: _________________________
(Virtual signature
) By checking this box, I agree that I have reviewed and complete this IEP with the student.
(Please email completed applications to
Grays Harbor College (GHC)
Workforce Funding and Support Programs Application
If you cannot answer yes to the following questions you DO NOT need to sign below. You MUST answer
YES to all the following questions before signing this area.
1. Have you been providing unpaid services to family member(s) in the home? Yes
2. Are you a dependent on the income of another family member but no longer supported
by that income? Yes
3. Are you unemployed or underemployed and experiencing difficulty obtaining or upgrading
employment? Yes
For Office Use Only
Date of Receipt of Application: __________________________
Continuous Non-Discrimination Notice
Grays Harbor College does not discriminate on the basis of race, color, national origin, sex, disability, sexual orientation, creed, religion,
marital status, veteran status, genetics, or age in its programs, activities, and employment. The following person has been designated to
handle inquiries regarding the non-discrimination policies:
Title II/Section 504 Coordinator
Darin Jones, Chief Executive of Human Resources
Grays Harbor College
1620 Edward P. Smith Drive
Aberdeen, WA 98520
Title IX Coordinator
Dr. Jennifer Alt, Vice President for Student Services
Grays Harbor College
1620 Edward P. Smith Drive
Aberdeen, WA 98520
By signing below, I certify that ALL three questions above I have answered yes to, apply to me, and I am
a displaced homemaker:
Signature _____________________________________ Date___________________________
(Virtual signature)
By checking this box, I agree that I have reviewed and complete this IEP with the student.
Ability To Benefit
ATB is for students who have not completed a High School credential (GED or Diploma) but would like to have access to financial aid and
are academically ready to take non-high school classes. In addition to participating in an eligible career pathway program, students can
become eligible for ATB by passing an approved test or successfully completing six college level credits. ATB allows a student to work on
completing high school while receiving financial aid and moving forward on a career path.
Would you like to be considered for this program?
Do you already know about this program?