Fill - Free fillable START Program Application (Diablo Valley College) PDF form

START – Program Application

GENERAL INFORMATION

SID #: _______________________________________

Last Name: __________________________________

Address: ____________________________________

City: _______________________________________

Zip: ________________________________________

Date of Birth: ____ /____ /____

First Name:_________________________________

Email: _____________________________________

Cell Phone #: _______________________________

Alternate Phone #:___________________________

FOSTER CARE BACKGROUND

LACEMENT

OUNTY

LACEMENTS

XITED

ARE

OF YEARS IN CARE

___ C

ONTRA

OSTA

___ ALAMEDA

___ SOLANO

___ SAN FRANCISCO

___ OTHER: _____

___ 1 - 2

___ 3 – 5

___ 6 – 10

___ MORE THAN 10

___

13 – 15

___ 16 – 18

___ 19 – 21

___ Still in care (AB12)

___ <1

YEAR

___ 1-3 YEARS

___ 4-6 YEARS

___ 7-10 YEARS

___ 10+ YEARS

EDUCATION HISTORY

Number of High Schools Attended: _____ High School Graduated From: ________________ Year Graduated: ______

1. Wh

at was your most difficult class in high school? ___________________________________________________

2. What class did you enjoy most in high school? ______________________________________________________

EMPLOYMENT INFORMATION

1. Are you currently employed? If yes, how many hours per week? _______

YES NO

2. Will you need to work while attending school?

YES NO

3. Are you interested in working on-campus?

YES NO

4. Do you need help finding a job?

YES NO

COMMUNITY RESOURCES & REFERRALS

5. Do you have children?

YES NO

6. Do you need childcare services?

YES NO

7. Are you in a transitional housing program?

YES NO

8. Do you need help finding immediate housing?

YES NO

9. Are you currently meeting with a therapist?

YES NO

10. If not, are you interested in participating in therapy?

YES NO

11. Do you need help finding a therapist?

YES NO

12. Do you have more than 1 person to turn to when problems come up?

YES NO

13. Do you have a juvenile or adult record? (You may be eligible for additional services)

YES NO

14. Do you need legal assistance or advice?

YES NO

15. Are you currently receiving CalFresh? (formerly called food stamps)

YES NO

16. If not, would you like to apply? (You may be eligible for additional services)

YES NO

TERM: FA: _______ SP: ______ SU:_____

REFERRAL SOURCE: ___________________

STAFF ONLY

Dependency Verified: _____ YES _____ NO Date: _______________ Initials: __________

Rev 10/24/19

CAMPUS SUPPORT

17. Do you know where to get your student ID card?

YES NO

18. Do you know where and how to buy text books?

YES NO

19. Would you like someone to show you the campus/where your classes are

located?

YES NO

20. Would you like support in navigating your InSite portal and/or student email?

YES NO

21. Do you feel comfortable asking for help or talking to your teachers?

YES NO

22. Do you feel you have strong notetaking and/or study skills?

YES NO

CAREER GOALS

1. What is your dream job? Why?

_________________________________________

2. How much money do you feel you need to make

to live comfortably?

_______________________________________

Do you know what major you need to get

your dream job? YES NO

If yes, what is it?____________________

3. How long do you see yourself at DVC?

___ 6 months – 1year

___ 1 – 2 years

___ 2 – 3 years

___ 3+ years.

COLLEGE SUCCESS ANALYSIS

1. How do/will you get to school every day?

___ Drive my own car

___ Public transportation (Bus, Bart,

Uber, etc.)

___ Get a ride

___ I’m not sure yet

2. How long will it take you to get to DVC?

___ < 30 minutes

___ 30 min – 1 hour

___ 1 – 2 hours

___ 2 + hours

___ I’m not sure yet

3. What time of day are you most

alert/focused?

___ Morning

___ Afternoon

___ Evening

4. Do you have access to a personal computer or

laptop to complete your school work?

YES NO

5. How many hours per week will you spend

on homework & studying?

___ >1 hour

___ 2 – 3 hours

___ 4 – 5 hours

___ 5 + hours

6. Is there anything else we need to know about

you to better help you succeed at DVC?

____________________________________________

On a scale of 1 – 5 please check how committed are you to going to college. (Be honest with yourself)

____ 1: Not committed (I was told to be here)

____ 2: A little committed (Meh, I’ll try it out)

____ 3: Neutral (School is okay)

____ 4: pretty committed (I feel like school is for me)

____ 5: Absolute committed (I’m all in! I’m here for me)

___________________________________ _________________________________

Student Signature Date

click to sign

signature

click to edit

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

START Program Application (Diablo Valley College)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank START Program Application (Diablo Valley College) Form

Related forms

Fillable START Program Application (Diablo Valley College)

Fill Online, Printable, Fillable, Blank START Program Application (Diablo Valley College) Form

Related forms

First 20 documents completely FREE!