Fillable Student Application WORKFORCE EDUCATION CENTER (Columbia Basin College)

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Student Application WORKFORCE EDUCATION CENTER (Columbia Basin College)

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File type: PDF

U.S.A. forms for Columbia Basin College

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Student program application for eligibility and services: BFET, Opportunity Grant, Worker Retraining and WorkFirst
APPLICANT INFORMATION
Name: Today’s Date:
Preferred Name (Nickname): Phone:
Date of Birth: SSN: SID:
Address:
City: State: Zip:
Are you a Washington resident? (Lived in WA 12 months or more) Yes No
Email (please print clearly):
Total Household Size: Number of Adults: Number of Children:
Number of children: 0-5 years: 6-12 years: 13-18 years:
EDUCATION INFORMATION
Program of Study: BAS AAS Certificate Other
Program Start Date:
Projected End Date:
Will you be attending:
Full-time (12+ credits) 3/4 time (9-11 credits) Part-time (6-8 credits) >Half-time (1-5 credits)
Do you have a high school diploma or GED?: Yes No
Are you currently enrolled in classes at CBC?:
Yes No
What is your highest level of education? Less than HS HS Diploma/GED Certificate
Associates Degree Bachelor’s Degree Post Bachelor’s Degree
Major:
Year Earned:
If you do not have a degree, how many prior college credits have you earned (from any college/university)?
None 1-30 31-60 61-90 91 or more Unsure
List all of the colleges or universities you have attended:
Have you completed an academic plan with a CBC advisor? Yes No
Have you previously (or currently) received services from any of these programs (at any school)? (Check all that apply)
BFET Opportunity Grant Worker Retraining WorkFirst Resource Center None of these
What programs are you interested in applying for? (Check all that apply)
BFET Opportunity Grant Worker Retraining WorkFirst
How did you hear about us?
WORKFORCE EDUCATION CENTER
Student Application
FINANCIAL INFORMATION
Total household income per month (include spouse or parents if applicable): $ per month
Are you currently receiving DSHS Cash Assistance? (TANF) Yes No
Are you currently receiving Social Security? Yes No
Are you currently collecting Veteran’s Benefits? Yes No
Are you currently receiving DSHS Food Assistance? (Food Stamps) Yes No
Have you applied for Financial Aid? (FAFSA/WASFA) Yes No
Are you currently receiving any other forms of Financial Aid? (Scholarships, WIOA, Trade Act, Loans, Etc.) Yes No
YES NO (Check all that apply)
Are you currently receiving unemployment benefits? WA State Other state
Have you exhausted unemployment benefits within the past 4 years? Date exhausted:
Are you currently working but have received a notice of layo? Date of layo:
Have you been supported by a family member but lost that support? (i.e. Displaced Homemaker)
Date support ended:
Have you been self-employed and experienced a lack of work due to economic factors?
Are you a U.S. Military Veteran? Discharge date:
Are you in active duty status in the U.S. armed services with less than 18 months to discharge?
Are you currently employed? Type of work: Employer:
Gross Monthly Wages: $
Do you need training to continue your current employment and have not earned a related certificate/degree?
Are you working in a temporary job earning less than you have previously?
Reason you left your previous job? Quit Fired Lack of Work
EMPLOYMENT HISTORY
Beginning with the most recent, provide the past five years of employment history. Attach another page if needed.
Employer name: Position title:
City, State: Hours per week:
Start date: End date:
Employer name: Position title:
City, State: Hours per week:
Start date: End date:
Employer name: Position title:
City, State: Hours per week:
Start date: End date:
Employer name: Position title:
City, State: Hours per week:
Start date: End date:
RELEASE OF INFORMATION AND ATTESTATION STATEMENT
CBC adheres to FERPA regulations regarding privacy and confidentiality of student information. Because the Workforce Education Center is
aliated with other agencies, we will need to share educational and financial aid information. Your signature authorizes CBC to release any
and all educational and financial aid information to our partner agencies including DSHS, Employment Security, WorkSource Partners, other
Community Agencies, and other colleges. Furthermore, it authorizes the above agencies to release information to CBC.
I agree to the release of information policy. I certify that the information provided on this document is true and accurate to the best of my
knowledge and belief. I understand that such information is subject to verification and further understand that the above information, if
misrepresented or incomplete, may be grounds for immediate termination from any/all of the Workforce Education Center programs and/
or penalties as specified by law.
Enter or sign your name below if you have read and understand the statement above and can certify that you provided accurate and complete
information on this form:
Student Signature: Date:
INDIVIDUALIZED EMPLOYMENT AND EDUCATION PLAN
Name: SID: Date:
Please describe your career goals, including:
Short-Term Goals (0-2 years):
Long-Term Goals (2+ years):
Why did you choose this career path? What led to the decision to choose this career?
Please list some of your strengths, skills, abilities, and/or interests that relate to this career path and will help you reach your
career goals:
Recommended services and referrals to address challenges:
What are some potential obstacles and challenges that you may encounter in pursuing your career and educational goals?
(Check all that apply)
Computer/Internet access Limited computer skills Lack of dependable childcare
Disability (physical, mental, or learning) Limited English proficiency Lack of reliable transportation
Limited time for school/work/family No GED or HS diploma Lack of family/friend support
Previous academic history/poor grades Finances (including educational costs and/or money management)
Limited/Negative work experience Lack of stable housing/homeless Legal issues or criminal history
Personal health issues or dependent with health issues Alcohol and/or drug use/dependency Other
What are your strategies to ensure that you complete your education and career goals?
BFET ELIGIBILITY AND PROGRAM REQUIREMENTS
The following are the requirements to participate in the Basic Food Employment & Training (BFET) Program:
• Receive Basic Food Assistance from DSHS
• Be able to work at least 20 hours per week upon completion of your training/education plan
• Follow your approved training/education plan (IEP)
• Make contact with your BFET advisor at least once each month
I,
, have read the requirements and agree to abide by them.
(Print your name)
Yes No I understand this form and the contents have been explained to me in my primary language.
Student Signature: Date:
Interpreter Signature: Date:
(Required if client cannot understand this form in English)
For Oce Use Only
Training/Education Plan: VE hours/week BE hours/week
Educational Institution: Columbia Basin College, Pasco, WA
Degree/Certification:
Dates of Training: Program Start Date Projected End Date:
BFET Advisor Signature: Date:
OPPORTUNITY GRANT ELIGIBILITY AND PROGRAM REQUIREMENTS
The following are the requirements to participate in the Opportunity Grant (OG) Program:
• Notify the OG oce as soon as you have completed your class registration and prior to any schedule change, including adding
or dropping a class
• Attend class(es) regularly and keep up with class assignments
• Make sure the OG oce has a workable email address that you will check frequently
• Inform the OG program of any changes in your address or phone number
• Inform the OG program of any academic or personal issues that conflict with your education
• Check-in with the OG oce once a month in person, by email or by phone
• Seek and accept employment upon completion of your certificate/degree
• Maintain satisfactory academic progress of 2.0 CUM GPA each quarter with completion of 50% of attempted credits
I understand the program expectations and my responsibilities as a recipient of the Opportunity Grant program.
Enter or sign your name below if you have read and understand the statement above:
Student Signature:
Date:
THE AREA BELOW IS FOR OFFICE USE ONLY
Reviewed By (int): Date:
Training Program: Prerequisites Certificate AAS BAS
SUMMER FALL WINTER SPRING # of credits
Courses enrolled are required for training program Full-time (12+) 3/4 time (9-11) Part-time (6-8) >Half-time (1-5)
Student Transcript (SM5003) (Transcript on Advisor Dashboard): Number of QTRs at CBC Last QTR attended
No prior completions Prior Certificate/Degree Year
# Of Cr attempted CUM Cr Earn GPA CLVL Cr Earn GPA Pace of progress: %
Credits from another college Prior Certificate/Degree Year
FAFSA/WASFA Date: Academic Year: EFC: $ Total Unmet Need: $
SAP: Good Academic Progress On FA Warning FA Canceled: Needs credits to become FA eligible
Comments:
Coding Check: Verify contact information and coding is correctly entered in HP-UNIX SMS screens
Admissions (SM2001): Current Name Current Address Current Phone(s) Adv Id Stu Typ
Registration/Admissions (SM4002): Work Attend Code (WRT=80s WF=60s or 70s WRT/WF co-enroll=50s)
Registration (SM7001) (Schedule on Advisor Dashboard): Res Fee Int Prg Purp Typ Adv
Student Unusual Action (SM5003): “B!” for BFET “OG” for OG “W!” for WRT (Stop Gap only)
Any other actions blocking registration?
Based on application information, this student could be eligible for:
BFET Opportunity Grant Worker Retraining WorkFirst (Share a copy of this application with each potential program)
Columbia Basin College complies with the spirit and letter of state and federal laws, regulations and executive orders pertaining to civil rights, Title IX, equal opportunity and afrmative action. CBC does not discriminate on the ba-
sis of race, color, creed, religion, national or ethnic origin, parental status or families with children, marital status, sex (gender), sexual orientation, gender identity or expression, age, genetic information, honorably discharged veteran or mili-
tary status, or the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal (allowed by law) by a person with a disability, or any other prohibited basis in its educational programs or employment. Ques-
tions or complaints may be referred to the Vice President for Human Resources & Legal Affairs and CBC’s Title IX/EEO Coordinator at (509) 542-5548. Individuals with disabilities are encouraged to participate in all college sponsored events and
programs. If you have a disability, and require an accommodation, please contact the CBC Resource Center at (509) 542-4412 or the Washington Relay Service at 711 or 1-800-833-6384. This notice is available in alternative media by request.
You have completed the application for eligibility and services for the Workforce Education Center programs:
Basic Food Employment & Training (BFET), Opportunity Grant (OG), Worker Retraining (WRT), and WorkFirst (WF)
Please return your completed application to the Workforce Education Center at Columbia Basin College:
2600 N. 20th Ave. MS-H2, Pasco, WA 99301
H Building (HUB) Room 208 (Across from the CBC Bookstore)
Phone: (509) 542-4719
CONSENT
DSHS 14-012(X) (REV. 04/2018)
Consent
NOTICE TO CLIENTS: The Department of Social and Health Services (DSHS) can help you better if we are able to work with other agencies and
professionals that know you and your family. By signing this form, you are giving permission for DSHS and the agencies and individuals listed below to
use and share confidential information about you. DSHS cannot refuse you benefits if you do not sign this form unless your consent is needed to
determine your eligibility. If you do not sign this form, DSHS may still share information about you to the extent allowed by law. If you have questions
about how DSHS shares client confidential information or your privacy rights, please consult the DSHS Notice of Privacy Practices or ask the person
giving you this form.
CLIENT IDENTIFICATION:
NAME
DATE OF BIRTH
IDENTIFICATION NUMBER
ADDRESS CITY STATE ZIP CODE
TELEPHONE NUMBER (INCLUDE AREA CODE)
CONSENT:
I consent to the use of confidential information about me within DSHS to plan, provide, and coordinate services, treatment, payments, and benefits for me
or for other purposes authorized by law. I further grant permission to DSHS and the below listed agencies, providers, or persons to use my confidential
information and disclose it to each other for these purposes. Information may be shared verbally or by computer data transfer, mail, or hand delivery.
Please check all below who are included in this consent in addition to DSHS and identify them by name and address:
Health care providers:
Mental health care providers:
Chemical dependency service providers:
Other DSHS contracted providers:
Housing programs:
School districts or colleges:
Department of Corrections:
Employment Security Department and its employment partners:
Social Security Administration or other federal agency:
See attached list
Other:
I authorize and consent to sharing the following records and information (check all that apply):
All my client records
Records on attached list
Only the following records
Family, social and employment history Health care information Treatment or care plans
Payment records Individual assessments School, education, and training
Other (list):
PLEASE NOTE: If your client records include any of the following information, you must also complete this section to include these records.
I give my permission to disclose the following records (check all that apply):
Mental health HIV/AIDS and STD test results, diagnosis, or treatment Chemical Dependency (CD) services
-
This consent is valid for one year as long as DSHS needs records, or until (date or event).
- I may revoke or withdraw this consent at any time in writing, but that will not affect any information already shared.
- I understand that records shared under this consent may no longer be protected under the laws that apply to DSHS.
- A copy of this form is valid to give my permission to share records.
SIGNATURE
DATE
AGENCY CONTACT/WITNESS SIGNATURE
DATE
PARENT OR OTHER REPRESENTATIVE’S SIGNATURE (IF APPLICABLE)
TELEPHONE NUMBER (INCLUDE AREA CODE)
DATE
If I am not the subject of the records, I am authorized to sign because I am the: (attach proof of authority)
Parent Legal Guardian (attach court order) Personal representative Other
:
NOTICE TO RECIPIENTS OF INFORMATION: If these records contain information about HIV, STDs, or AIDS, you may not further disclose that
information without the client’s specific permission. If you have received information related to drug or alcohol abuse by the client, you must
include the following statement when further disclosing information as required by 42 CFR 2.32:
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you
from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it
pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medial or other information is NOT sufficient for this
purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
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Columbia Basin College 2600 N. 20th Ave. Pasco, WA 99301
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Career Path/BFET ESD 815 N Kellogg Kennewick, WA 99336
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Other BFET Providers
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Student Application WORKFORCE EDUCATION CENTER (Columbia Basin College)

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Completed 21 July 2020

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