CalWORKs Program Case#______
Intake Form Major______
EOPS CARE SIP VOC PES POST Student ID# ______Time Limit ______
Last Name______First Name______Middle Init ______
Address ______City ______State______Zip______
Phone: Home (_____)______Cell ( __ )______
Date of Birth ______Social Security Number ______Female Male
E-Mail Address: ______
My preferred written language: ______My preferred spoken language: ______
Marital Status: Single Married Family Status: Single Parent Family Two Parent Family
Number of Children ______
Names/DOB: #1______/___/___ F M #3______/___/___ F M
#2______/___/___ F M #4______/___/___ F M
Number of Children receiving CASH Aid ______Is your Child Care provided: ON campus OFF-campus
EDUCATIONAL INFORMATION:
Highest grade completed ______High School Diploma or GED (please circle one)
Have you ever attended college? Y / N If yes, give name of college______
College major: ______
Educational Goals: AA/AS Degree: ______Certificate: ______Transfer to University: ______
Are you currently employed? Y / N Name of Employer:______Hours:______
Address:______Wage: ______
Have you seen a Counselor at RHC? Yes No If yes, Counselor’s name: ______
Have you taken the Assessment Test? Yes No Are you interested in work study? Yes No
Were you/are you in Counseling for any of the following:
Domestic Violence:______Substance Abuse:______Mental Health:______
Do you have a criminal background? Yes No
Are you in the GAIN Program? Yes No Have you signed a GAIN contract? Yes No
If yes, GAIN Worker’s Name ______GAIN Worker File # ______
GAIN Office______Worker’s Phone # ______Worker’s Fax #______
Unit Assistant #______GSW Supervisor #______
WAIVER OF CONFIDENTIALITY:
I authorize Rio Hondo 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, Referring Agency, or other agencies, if and when required to do so. I affirm that all the information that I have provided on this intake form is correct. In addition, I acknowledge that I have received my Civil Rights. ______Initials:
Student’s Signature: ______Date:______
Rev.11-14