Fillable New Student Intake

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New Student Intake

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  • 75 check-boxes
  • 56 other fields

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File type: PDF

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CW IN-TAKE (R 3/24/16) BGAMEZ
CalWORKs New Student INTAKE FORM
Please read and inial ALL statements below.
I authorize the ocials of Cerritos College to transmit informaon to any agency, company or person regarding my academic
progress and any other pernent educaonal data.
I agree to nofy the Cerritos CalWORKs Oce of any changes made during the semester aer compleng this New Student In
take Form.
I understand that to be compliant with the CalWORKs program I must meet with a CalWORKs Counselor to update my
Educaonal Plan, submit a Work-In Progress (WIP) Form and Cash-Aid eligibility (Noce of Acon/Vericaon of Benets) EVERY
Semester.
I agree acknowledge and agree to the terms above.
Student Signature: ____________________________________________ Date: ____________________________
Personal Informaon: (SC06-10)
Name: _________________________________________ Student #:___________________ Date of Birth: __________________
Email: ___________________________________________________ Phone Number: __________________________
Current Home Address: _____________________________________ City: __________________________ Zip Code: ___________
Primary Language: _______________________________________ Proof to Work in U.S.: Yes No
Marital Status: Single Married Separated Widow (er)
Unmarried, but living together
If marked “Unmarried, but living together” are you and your partner on the same case? Yes No
Number of children in household under the age of 18: ____________ Are you currently receiving Child Care? Yes N o
Name and Age of Children: 1)_____________________ 2) _____________________ 3) _____________________
Is this your FIRST me parcipang in the GAIN program? Yes No If no, when was your rst me? ____________
Is this your FIRST me receiving CASH-AID? Yes No If no, when was your rst me? ________________________
GAIN Informaon: (SC01)
GAIN Service Worker Name: ___________________________________ 4-Digit File Number: _____________ Case #: _____________
GAIN Oce Address: ________________________________________________________________________________________
City: __________________________________ Zip Code: __________ Phone: _____________________ Fax: ___________________
OFFICE USE ONLY
GN6005A GN6006+ 6013/6014 Post-Time Limit Mulple-Schools Semester Term: _____________
Counselor: _______________________________________ Appointment: Time: ______________ Date: _________________
CW IN-TAKE (R 3/24/16) BGAMEZ
Are you a current/former foster youth? : Yes No If yes, since when: ______________________
Are you a current/former member of the United States Armed Forces? : Yes No If yes, since when: ________________
*If Yes, Please refer to LINC/
Veterans Educaon Oce
Educaon:
Do you have a: H.S Diploma GED None If none, highest grade completed: __________________
Are you currently enrolled in Cerritos College? Yes No Start Date: _______________________________
Major: _________________________________________________________________________________________________________
Have you ever aended another college? Yes No
If yes, please aach OFFICIAL transcripts and provide name of school: _____________________________________________________
Degree/Cercate Obtained:_____________ Major: _________________________________________ Units Completed: ____________
Educaonal Goals:
Cercate AA Degree Transfer AA/Transfer Associate Degree Transfer (ADT)
Short Term Career Goals: ________________________________________________________________________________________
Long Term Career Goals: _________________________________________________________________________________________
Are you receiving Financial Aid from Cerritos College? Yes No
If no, why: ______________________________________________________________________________________________________
Employment: (SC011-17)
Are you currently employed? Yes No If yes, name of company or employer: ____________________________________
Title or job descripon: ____________________________________________________________________
Start Date: __________ Hours worked per-week:_______ Highest hourly wage $________ Is this posion volunteer? Yes No
Are you receiving college credit for this posion? Yes No
If no, would you be interested in working on campus through our CalWORKs work-study program? Yes No
Are you currently ulizing any services provided by any of these departments? (Check all that apply)
CARE Foster Care (LINK)
Disabled Student Program and Services (DSPS) Health Center
EOPS Student Success Center
Financial Aid Transfer Center
Financial Aid Work-Study Veterans Aairs
If you answered NO to any of the departments above, would you like to receive more informaon from that department? Yes N o
CW IN-TAKE (R 3/24/16) BGAMEZ
Language Designaon Form
Name: _________________________ Case Number: ___________________ Date: _____________
FREE INTERPRETER SERVICES ARE AVAILABLE
(please ask your worker)
A. SPOKEN LANGUAGE DESIGNATION:
I Speak the language checked below. I prefer to speak/talk about my case or related maers with sta from
the Department of Public Social Services in the language selected below. This designaon takes the place of
any choices made before.
Armenian Cambodian Cantonese English
Spanish Korean Mandarin Russian
Tagalog Vietnamese Other (Specify) _______________________
B. WRITTEN LANGUAGE DESIGNATION:
I prefer to get wrien leers, noces, forms, and other communicaon in English.
OR
I prefer that wrien communicaons and forms be sent or given to me, if available, in the language specied
below (Chinese is the wrien language for those who speak Cantonese and Mandarin). In addion, I
understand that id wrien communicaons from the Department of Public Social Services are not available in
the language specied below, I can receive verbal translaon by contacng my case worker.
Armenian Cambodian Cantonese English
Spanish Korean Mandarin Russian
Tagalog Vietnamese Other (Specify) _______________________
Applicant’s/Parcipant’s Signature (or mark) : ________________________ Date: __________________
I hereby verify that the applicant’s/parcipant’s above choices are reected on LEADER and/or GEARS and/or
CMIPS and/or any other computer program used to manage eligibility issues.
Case Carrying Workers Signature: ______________________ File Number: __________________ Date: ____________
Supervisor’s Inials: _____________________
Filling Instrucons:
BSW/BSO: Documentaon/Acvity Folder
Retenon: Permanent
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New Student Intake

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Completed 8 May 2020

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