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
Monthly Gross
Family Income (2020)
For each addl 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
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
Advisor: _____________ Date: _____/_____/_____ Time: ______________
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/partners earnings: $__________ Weekly Bi-weekly Monthly Other _________________
Social Security: $_____________________ Veterans 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 Associates Degree (major) _____________________
Some High School Less than 45 college credits Bachelors Degree (major) _____________________
Graduated High School 45 college credits or more College Cercate Masters 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
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 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
425-564-2178 Office R130.
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