SMC Calworks PROGRAM APPLICATION

SMC CalWORKs PROGRAM APPLICATION

California Work Opportunity and Responsibility to Kids Today’s Date: ____/____/____

PERSONAL INFORMATION (please print)

Last Name _________________________ First Name _________________________ Middle ______________ SMC ID# __________

Date of Birth ____/____/____ Place of Birth (city/country)_________________________________ £ Female £ Male

Phone #1 ( )__________________ Phone #2 ( )__________________ E-mail ______________________________

Address ________________________________ City __________________________ State ______ ZIP Code __________

Marital status: £ Single £ Married £ Separated £ Divorced £ Widowed

Number of children: _____ Do you have childcare? £ Yes £ No

Names/Dates of Birth: #1 _________________/___/___/___ £ F £ M #3 _________________/___/___/___ £ F £ M

#2 _________________/___/___/___ £ F £ M #4 _________________/___/___/___ £ F £ M

My preferred written language: __________________________________

My preferred spoken language: __________________________________

Are you receiving AFDC/TANF CalWORKs cash benefits? £ Yes £ No If YES, case # ___________________

If YES, date benefits began: ____/____/____ If NO, date benefits ended: ____/____/____

Are you in the GAIN Program with the Department of Social Services? £ Yes £ No

GAIN Worker’s Name ______________________________ GAIN Worker’s File # ____________________

GAIN Office _____________________ Worker’s Phone # ( )__________________ Worker’s Fax # ( )__________________

EDUCATIONAL BACKGROUND

Year you last attended: High School: _____ College: _____ Other: _____

From list below, check highest schooling level completed:

£ 1-8 years £ Associate Arts: Major: _____________________

£ 9-11 years (no H.S. diploma) £ Bachelor of Arts: Major: ____________________

£ High school diploma or G.E.D. £ Masters Degree: Major: ____________________

£ Some college (no degree): # of units _____ £ Other: Subject: ___________________________

Have you already seen a counselor at SMC? £ Yes £ No If YES, where on campus? _________________________

Have you taken the SMC ESL/English Placement Test? £ Yes £ No

Have you taken the SMC Math Placement Test? £ Yes £ No

SMC major or career goal: ______________________ £ A.A. Degree £ Certificate/Vocational Program £ General Education

Have you applied for financial aid at SMC? £ Yes £ No

Are you part of the EOPS/CARE Program? £ Yes £ No

EMPLOYMENT INFORMATION

Are you currently working: £ Yes £ No If YES, employed by: ___________________________ since: ____/____/____

If YES, £ Off-campus Employment: Job: _________________________ # of hours per week: _____ salary per hour: $_____

£ On-campus Work Study: Job: __________________________ # of hours per week: _____ salary per hour: $_____

£ Off-campus Work Study: Job: __________________________ # of hours per week: _____ salary per hour: $_____

WAIVER OF CONFIDENTIALITY

I authorize the Santa Monica College CalWORKs staff to disclose my school attendance, academic progress, assessment results, childcare resources and work-study information to the Department of Public Social Services and/or Children’s Resource and Referral, if and when required to do so. I affirm that all the information that I have provided on this CalWORKs Program Application is correct.

_____________________________________________ ____/____/____

Student’s Signature Date

SMC Application 11//15/12