EOPS/CARE Application

EOPS/CARE Application & Intake Form

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone Number:

eMail Address:

SSN:

ID#:

Date of Birth:

Have you ever enrolled in any school under a different name?

Yes No

If yes, please specify:

Gender:

Male Female

Ethnicity:

Do you have a high school diploma, GED, or equivalent?:

Yes No

High School Attended:

High School GPA:

Are H.S. Transcripts at COD?:

Yes No

Year Grad./ Left School:

If new to EOPS, have you ever attended COD before?:

Yes No

If "Yes", when did you attend? (Dates):

Have you ever attended any colleges besides COD?:

Yes No

If "Yes", list colleges:

Total units other colleges?:

Did you take any basic English, Reading, or Math courses?:

Yes No

Do you have an AA/As Degree?:

Yes No

Do you have a Bachelor's Degree?:

Yes No

Are you a U.S. Citizen?:

Yes No

If "No", do you have a Permanent Resident Card?:

Yes No

Did either of your parents earn a Bachelor's Degree?:

Yes No

Are both of your parent's Native English speakers?:

Yes No

Education Goals:

Major:

Are you in DSPS?:

Yes No

Have you completed the FAFSA (Free Application For Federal Student Aid)?:

Yes No

If you are receiving CalWORKs/TANF, please continue. Otherwise, please select "Submit" button at bottom of page.

Are you at least 18 years of age and currently enrolled at COD for 12 units or more?

Yes No

Are you receiving cash aid through CalWORKs/TANF for at least one child under age 14?

Yes No

Date Started CalWORKs/TANF:

How long have you been on CalWORKs/TANF (formerly AFDC/GAIN)?

Marital Status

Please list names, ages and birthdays of your child(ren) below:

Full Name	Age	Date of Birth

Do you need assistance with out-of-pocket child care expenses for any of your children?:

Yes No

If you are selected for the CARE Program, what is your main reason(s) for coming to College of the Desert?:

How did you hear about the CARE Program?: