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You must have a dependent child under the (National Park College)

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U.S.A. forms for National Park College

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You must have a dependent child under the age of 21 who lives in the home on a permanent
basis AND have annual income below the 250% poverty level listed in the column below,
AND provide copies of the documents listed below.
2020 HHS Poverty Guidelines
Persons in Family or Household
250%
Annual
2
$43,100
3
$54,300
4
$65,500
5
$76,700
6
$87,900
7
$99,100
8
$ 121,500
Documents to be provided ONLY after notification that application is accepted for
eligibility determination:
1. Signed copy of most recent federal income tax return
2. Court Document for custody if applicable
3. Copy of applicant’s driver’s license & SS card
4. Copies of each child’s SS card AND birth certificate or hospital proof of birth
5. Benefit Verification Form from the DHS office (food stamps, Medicaid, ARKids,
TEA). If you do not receive benefits, you must bring the form stating this.
6. Proof of income (last check-stub)
Do not submit these documents with the application unless you are a GED or TEA
student. Career Pathways staff can be reached at 501-760-4238.
Updated 9/2/2020
Arkansas Career Pathways Initiative Application
National Park College
The following information is requested to determine eligibility to participate in the Career Pathways
Initiative (CPI). You will be contacted with more information about the program if you appear eligible
to participate in the CPI. Completing this form does not commit you to participate in the program.
Please Print Date:
Name: Maiden Name:
Address: City: Zip: County:_
Phone: Alternate Phone
Emergency Contact: Relation: Phone
Social Security: Birthdate:
E-mail:
Race: ☐ Asian/Pacific Islander
☐ Black (Non-Hispanic Origin)
Gender: ☐ Male ☐ Female
☐ Hispanic
☐ American Indian or Alaska Native
Are you a single parent?
☐ White (Non-Hispanic Origin)
☐ Yes ☐ No
☐ Other
Applicant Information
Current Employment Status
☐Part-time, ☐Full-time, ☐Seasonal,
☐
Self-employed,
☐
Unemployed
Name of Employer:
Time with Employer in months
Your monthly salary:
Do you currently receive:
TEA: □Yes
□No
Workpays: □Yes
□No
Food Stamps: □Yes
□No
AR Kids □Yes
□No
Medicaid □Yes
□No
Have you earned a: HS Diploma GED (date obtained ) Want to earn a GED
Date enrolled in GED:
Are you currently enrolled in College?
Yes
No Where?
Program/Major?
Have you applied for Financial Aid (Pell Grant)?
Yes
No
Additional
Information
Which Career Pathways services are you seeking?
☐ Transportation (gas cards) ☐ Tuition ☐ Books ☐ Child Care ☐ Supplies
How did you hear about Career Pathways?
By signing below, I give full permission to the CPI staff at National Park Community College to
review my financial and academic records including but not limited to my FAFSA application,
income tax return, if requested, test scores, transcripts, and participation with DHHS programs.
This information will be used to determine my eligibility to participate in CPI. The program may
also access pertinent records related to my employment and attendance/graduation.
Also, by signing below, I verify that I am a parent, with a child under the age of twenty-one that
lives with me in my residence, on a full time, permanent basis.
By signing below, I understand I will not be eligible for monetary services if my grade point
average is below or falls below 2.0.
Signature Date
The above information will provide enough information to begin a review to assess your current
needs. Submission of this form authorizes CPI to communicate with any person or persons to verify
the foregoing information, including but not limited to earnings from employers, and to contact
financial institutions for financial data and any other agency or persons regarding your financial
condition. Assistance is not guaranteed.
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Pathways Release Form
I authorize the following agencies: National Park College, Arkansas
Department of Higher Education, Department of Health and Human Services, Department of Workforce
Services, Adult Education, and Department of Workforce Education, to share pertinent information about
myself, and my children (see page 2) for the process of verifying my eligibility, to track my progress in the
Arkansas Career Pathways Initiative, and to track my progress after leaving the Arkansas Career Pathways
Initiative. The information that will be shared includes but is not limited to: name, date of birth, and social
security number. This release form can be revoked at any time with a written statement from me.
Student’s Signature:
Date Signed:
Pathways Promotional Release Form
I authorize, with prior notification, my name and photograph to be used in
newspapers, newsletters or other public awareness components for the state agencies listed above or college I
attend in conjunction with the Arkansas Career Pathways Initiative. This release form can be revoked at any
time with a written statement from me.
Student’s Signature:
Date Signed:
Child Disclosure
I verify that I am a parent, with a child under the age of twenty-one that lives
with me in my residence, on a full time, permanent basis.
Student’s Signature:
Date Signed:
Witnessed by:
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AUTHORIZATION TO RELEASE OR OBTAIN INFORMATION FOR THE CAREER PATHWAYS INTIATIVE
In the course of providing the best possible service to the participants of the Arkansas Career Pathways Initiative
Program, the exchange of information between governmental agencies and educational Institutions may be necessary.
hereby authorize the Arkansas Career Pathways Initiative personnel to release and/or provide, on a need to know
basis, information which is reasonably necessary to accomplish the goals and objectives of the Pathways program. I
understand the individuals that receive and use this information will hold it in the strictest confidence and will use it to
better serve me. Non-personally identifiable information can be shared by ADHE/CPI with other entities to promote the
program both inside and outside the state. I understand copies of this signed release will serve as valid authorization
and the original signed document will be kept in my file. I understand that government records may be used to obtain
this information.
I hereby authorize release of the following information to the following agencies, institutions or other parties unless the
release or provision of such information is otherwise prohibited by law or regulation:
The Department of Health and Human Services and the Division of Child Care and Early Childhood Education
(DHHS/DCCECE) may provide Information regarding my participation in agency programs. This will include names,
social security numbers and other necessary information pertaining to my children.
The Department of Workforce Services ( DWS ) may provide information regarding my participation in the
Transitional Employment Assistance (TEA) program, unemployment insurance benefit program and my participation
in Workforce Investment Act employment and training programs
The Department of Career Education may provide information including WAGE, Adult Education and current and
past education participation.
The Arkansas Department of Higher Education and affiliated educational institutions may provide records relating to
my current and past education.
The educational institution involved in my participation in the Career Pathways Initiative may provide information
between the internal departments.
The Workforce Investment Act service provider may provide information regarding my participation in adult work
programs.
The Division of Rehabilitation Services may provide information regarding my participation in Rehabilitation Services
employment and training programs.
The Department of Education and local school districts may provide information regarding my current and past
education.
Private and career training institutions may provide records relating to current and past training and education. My
current and past employers may provide information related to my employment.
My likeness may be used for public relations purposes in the media including newspapers, newsletters, TV ads, and
other media venues.
As a condition to my authorization the Arkansas Career Pathways Initiative agrees to use the information obtained
solely for the purposes authorized by law and regulation Including determining eligibility for employment and training
programs, developing an appropriate employment or self-sufficiency plan, educational training and plans, and helping
me achieve my occupational and education goals. This authorization can be revoked at any time with a written
statement from me. This authorization is valid for the purpose of obtaining information for program performance
reporting and participant follow-up activities related to pre-participation and post exit employment and earnings and for
the purpose of obtaining educational information relating to my participation in the Career Pathways Initiative. I
understand that, as a condition of my receiving services, information collected by the Career Pathways Initiative will be
used for purposes of determining overall program performance.
Student's Signature Print Name
Da
te Effective January 1, 2012
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Please provide the names & DOB of all your children currently living with you:
Childs Name: DOB
Childs Name: DOB
Childs Name: DOB
Childs Name: DOB
Childs Name: DOB
Childs Name: DOB
To be submitted with application: Tell us about yourself. Please write at least two paragraphs on
this sheet, or attach a typewritten sheet, describing your educational/employment goals and how
Career Pathways can help you achieve these goals. Be sure to list specific needs, so that we can
best evaluate you for the program.
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You must have a dependent child under the (National Park College)

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Completed 28 January 2021

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