STARTProgram Application
GENERAL INFORMATION
SID #: _______________________________________
Last Name: __________________________________
Address: ____________________________________
City: _______________________________________
Zip: ________________________________________
Date of Birth: ____ /____ /____
First Name:_________________________________
Email: _____________________________________
Cell Phone #: _______________________________
Alternate Phone #:___________________________
FOSTER CARE BACKGROUND
P
LACEMENT
C
OUNTY
:
#
OF
P
LACEMENTS
A
GE
E
XITED
C
ARE
:
#
OF YEARS IN CARE
___ C
ONTRA
C
OSTA
___ ALAMEDA
___ SOLANO
___ SAN FRANCISCO
___ OTHER: _____
___ 1 - 2
___ 3 – 5
___ 6 10
___ MORE THAN 10
___
1315
___ 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? _______
2. Will you need to work while attending school?
3. Are you interested in working on-campus?
4. Do you need help finding a job?
COMMUNITY RESOURCES & REFERRALS
5. Do you have children?
6. Do you need childcare services?
7. Are you in a transitional housing program?
8. Do you need help finding immediate housing?
9. Are you currently meeting with a therapist?
10. If not, are you interested in participating in therapy?
11. Do you need help finding a therapist?
12. Do you have more than 1 person to turn to when problems come up?
13. Do you have a juvenile or adult record? (You may be eligible for additional services)
14. Do you need legal assistance or advice?
15. Are you currently receiving CalFresh? (formerly called food stamps)
16. If not, would you like to apply? (You may be eligible for additional services)
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?
18. Do you know where and how to buy text books?
19. Would you like someone to show you the campus/where your classes are
located?
20. Would you like support in navigating your InSite portal and/or student email?
21. Do you feel comfortable asking for help or talking to your teachers?
22. Do you feel you have strong notetaking and/or study skills?
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
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