Fillable INTAKE/ELIGIBILITY FORM WORKFORCE EDUCATION

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INTAKE/ELIGIBILITY FORM WORKFORCE EDUCATION

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WORKFORCE EDUCATION
INTAKE/ELIGIBILITY FORM
Name: __________________________________________________________ Date: ____________________________
(Last) (First) (MI)
SSN: _______________________ Date of Birth: _______________________ SID: _____________________________
Address: ________________________________________________________________________________________
(Number & Street) (City) (State) (Zip)
Phone: _____________________________ Email Address: ________________________________________________
☐ Yes ☐ No Are you planning on pursuing a degree in Diagnosc Ultrasound, Neurodiagnosc Technology,
Nuclear Medicine Technology, Nursing, Radiaon Therapy, or Radiologic Technology?
If YES, will you be taking prerequisites at Bellevue College? ☐ YES ☐ NO
☐ Yes ☐ No Have you completed a Bachelors Degree or higher? If YES, what country? ________________________
☐ Yes ☐ No Have you lived in Washington State for the last 12 months?
☐ Yes ☐ No Are you a U.S. cizen? If NO, what is your status? ☐ Permanent ☐ Asylee/Refugee ☐ Other _________
☐ Yes ☐ No Are you at or below these income guidelines?
☐ Yes ☐ No Are you currently receiving Basic Food Assistance?
☐ Yes ☐ No Have you been idened by DSHS as an Able Bodied Adult Without
Dependents (ABAWD)?
☐ Yes ☐ No Are you a parent receiving TANF (Temporary Assistance for Needy Families)
cash grant from DSHS?
If YES; do you ancipate closing your TANF in the next 30 days? ☐ YES ☐ NO
☐ Yes ☐ No Are you currently Acve Duty Military with a separaon date?
☐ Yes ☐ No Are you currently working?
If YES ; Have you received a wrien layo noce? ☐ Yes ☐ No
Do you need to learn new skills to Keep your job? ☐ Yes ☐ No
Are you in a declining occupaon? ☐ Yes ☐ No
Do you have a college cercate/degree? ☐ Yes ☐ No
☐ Yes ☐ No Are you currently receiving or have applied for Unemployment Insurance benets?
In the last 48 months, have you:
☐ Yes ☐ No Exhausted all Unemployment Insurance benets (mm/yy: ____/____ ) and have not returned to work?
☐ Yes ☐ No Been discharged from the Armed Forces? (mm/yy: ____/____)
☐ Yes ☐ No Become a displaced homemaker (divorced/widowed and lack work skills/experience)? (mm/yy: ____/____)
☐ Yes ☐ No Closed your business due to industry decline? (formerly self-employed) TURN OVER
ELIGIBILITY INFORMATION
Family
Size
Monthly Gross
Family Income (2020)
1
2,127
2
2,873
3
3,620
4
4,367
5
5,113
For each add’l person, add $746
For screening purposes only: Reviewed by: ____________
Inial Eligibility (check all that apply) and CIRCLE Primary Program
BFET OG WF WR Not Eligible (Reason:____________________)
To Follow Up Call to make appt. Student will contact us later
Notes:
Starng Qtr:
Review Date ____/____/____
Former WE Yes No
Last WE Qtr.
BF Status
from eJas
Food Open
eJas Acvity
Does not meet
BF Criteria
SSN not found
By
INTAKE APPOINTMENT
Advisor: _____________ Date: _____/_____/_____ Time: ______________
Admin
Updated: 12/04/20
☐ Yes ☐ No Are you receiving assistance from Eastside King County Housing Authority or Secon 8?
Number of dependents in your household: Self: 1 + Spouse ____ + Children younger than 18____ + Others____
Unemployment Insurance benets (UI): $_____________/week Date UI Opened: _____/_____/_____
Current work earnings: $____________ ☐ Weekly ☐ Bi-weekly ☐ Monthly ☐ Other _________________
Spouse/partner’s earnings: $__________ ☐ Weekly ☐ Bi-weekly ☐ Monthly ☐ Other _________________
Social Security: $_____________________ Veteran’s Benets: $ ___________________
Do you pay child support? If yes, how much $___________________ /month
Do you receive child support? If yes, how much $___________________ /month
Other Income: $_____________________ Specify Source: ____________________________________________
Have you completed:
☐ Below High School ☐ GED ☐ Associate’s Degree (major) _____________________
☐ Some High School ☐ Less than 45 college credits ☐ Bachelor’s Degree (major) _____________________
☐ Graduated High School ☐ 45 college credits or more ☐ College Cercate ☐ Master’s and Above
☐ Yes ☐ No Have you ever aended Bellevue College?
☐ Yes ☐ No Are you currently aending Bellevue College?
Most recent Job Title: _______________________________________________________________________________
What program of study interests you? _________________________________________________________________
How long do you plan to be in school? ☐ Less than one year ☐ One Year ☐ Two Years
What types of jobs do you hope to obtain aer compleng your training? _____________________________________
________________________________________________________________________________________________
I, _________________________________________________, give permission for the Washington State Department of Social and Health Services
and Bellevue College to use and share condenal informaon about me (except as limited below) as necessary for Employment and Training (E&T)
acvies as required by the BFET program.
This consent is valid for a maximum of three years from the date signed, unless I withdraw or change my consent in wring. This consent DOES NOT
permit sharing of sensive informaon about my mental health, chemical dependency, HIV/AIDS and STD test results, diagnosis or treatment.
I understand that I must ll out a separately approved consent form if I am under 18 years of age, I want to further limit informaon shared about
me, someone else is represenng me in this maer, or I want to allow sharing of sensive informaon about my mental health, chemical
dependency, HIV/AIDS and STD test results, diagnosis or treatment.
Bellevue College adheres to FERPA regulaons regarding the privacy of student informaon. The informaon you give us is condenal. Your
signature authorizes us to release informaon to, and obtain informaon from, our partners. Our partners include: Employment Security,
Department of Social & Health Services (DSHS), Workforce Investment Act (WIA) and other internal oce sta of Bellevue College (BC).
By signing below, you cerfy that the above informaon is true and correct to the best of your knowledge.
___________________________________________________________________________ ____________________________
Student Signature Date
FOR ELIGIBILITY PURPOSES: Authorizaon for Release of Informaon
EDUCATION INFORMATION
HOUSEHOLD INFORMATION
In accordance with Federal civil rights law, U.S. Department of Agriculture (USDA) and Bellevue College, Workforce
Education does not discriminate on the basis of race, color, national origin, language, ethnicity, religion, veteran status,
sex, sexual orientation, including gender identity or expression, disability, or age in its programs and activities. Please
see policy 4150 at www.bellevuecollege.edu/policies/. The following people have been designated to handle inquiries
regarding non-discrimination policies: Title IX Coordinator, 425-564-2641, Office C227, and EEOC/504 Compliance
Officer,
425-564-2178 Office R130.
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INTAKEELIGIBILITY FORM WORKFORCE EDUCATION

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Completed 7 December 2020

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