SOCIAL SECURITY NUMBER STUDENT ID NUMBER
NAME DATE OF BIRTH
STREET ADDRESS
CITY STATE ZIP
PHONE EMAIL
ARE YOU CURRENTLY RECEIVING ANY OF THE FOLLOWING BENEFITS?
2018-19 Workforce Education – Special Program Funding Application
(Worker Retraining, WorkFirst, Basic Food Employment and Training, Opportunity Grant)
AP
PLICANT INFORMATION - RENEWAL
PROGRAM INFORMATION
HAVE YOU LIVED IN WASHINGTON STATE FOR THE PAST 12 MONTHS?
YES NO
ARE YOU A DISPLACED HOMEMAKER?
YES NO
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF)
EJAS # (if known)
We adhere to FERPA regulaons regarding the privacy of student informaon. The informaon you give us is condenal.
Your signature authorizes Edmonds Community College to release any and all educaonal and nancial informaon to
our partner agencies including WorkSource partners, Employment Security, the Department of Social and Health Services
(DSHS), community colleges, internal Edmonds CC faculty/sta. I cerfy that this informaon provided is true to the
best of my knowledge. I also authorize Employment Security to release informaon to Edmonds CC for the purpose of
determining eligibility for the Worker Retraining Program and to provide employment informaon.
SIGNATURE DATE
AUTHORIZATION
BASIC FOOD COLLECTING OR EXHAUSTED
UNEMPLOYMENT
LESS THAN HIGH SCHOOL HIGH SCHOOL/GED® SOME COLLEGE DEGREE (two-, four-year or other)
PROGRAM OF STUDY PROGRAM CODE
HIGHEST EDUCATION LEVEL ATTAINED:
HAVE YOU FILED THE FAFSA FOR FEDERAL FINANCIAL AID?
YES NO
IF YOU ARE NOT FAFSA ELIGIBLE, HAVE YOU FILED THE WASFA?
YES NO
HAVE YOU RECEIVED AN OPPORTUNITY GRANT AT ANY OTHER WASHINGTON STATE TECHNICAL OR COMMUNITY COLLEGE?
YES NO
HOW DID YOU HEAR ABOUT THESE SPECIAL FUNDING PROGRAMS?
Edmonds Community College does not discriminate on the basis of race; color; religion; national origin; sex; disability; sexual orientation; age; citizenship, marital, or veteran status; or genetic information in its programs and activities.
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DO YOU NEED CHILDCARE TO ATTEND COLLEGE? YES NO
ARE YOU A VETERAN?
YES NO
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signature
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