Mt. San Jacinto College
CalWORKs Application
D
ate: _______________
Semester: FA___SP___ SU___ 20_____
Last Name: ______________________________ First Name: _______________________ Middle Initial: ______
Student I.D.:___________________________ S.S. #___________________________________________________
Address: ____________________________________City: ____________________ State: _____ Zip: __________
Email: _____________________________________ Home Phone: ________________Cell: __________________
Gender: Male___ Female___ Date of Birth: _____________ Household: Single-parent ___ Two-parent ___
Ethnicity: (check one)
M
SJC Campus: ____ San Jacinto ____ Menifee ____ Temecula ____ San Gorgonio Pass
S
tudent signature: _______________________________________________ Date: _______________________
Reviewed by: ___________________________________________________ (CalWORKs Counselor)
Program Eligibility
Are you currently enrolled at Mt. San Jacinto College? ____Y ____N
Are you currently receiving cash aid for yourself and at least one child? ____Y ____N
How many children in your household are under the age of 18? ______
Consent for Release of Information
I, the undersigned, consent to and request the County of _________________________ to release information regarding myself to the
MSJC CalWORKs Program for use in educational/vocational planning and for evaluating my participation in the CalWORKs Welfare
to Work activity. I authorize the release of information which may include one or more of the following: Name, Address, Phone, SS#,
DOB, Other Pertinent Information.
I, the undersigned, consent to and request the MSJC CalWORKs Program to release information regarding myself consistent with the
Federal Family Education Rights and Privacy Act of 1974, or other laws, regulations, or policies of the Department of Public Social
Services for use in participation evaluation for CalWORKs. All information will be kept confidential and maintained as part of my
records with the CalWORKs office at MSJC. Additionally, all information will be used exclusively in the administration or delivery of
services. This release shall remain in effect during my enrollment or until revoked in writing by the undersigned.
____
_____________________________________________________ ______________________
Student: Last First M.I. Student ID
_________________________________________________________ _______________________
Student Signature Date
____
______________________________________________________ ________________________
MSJC CalWORKs Staff Signature Date
American Indian /
Alaska Native
Hispanic / Latino /
Mexican American
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
