Application for Student Support Programs 1/4/19 - 1/31/19 Question Title * 1. First Name OK Question Title * 2. Middle Initial OK Question Title * 3. Last Name OK Question Title * 4. COS ID OK Question Title * 5. Date of birth Date / Time Date OK Question Title * 6. Mailing Address OK Question Title * 7. City OK Question Title * 8. State OK Question Title * 9. Zipcode OK Question Title * 10. Student email OK Question Title * 11. Personal email OK Question Title * 12. Phone number OK Question Title * 13. Alternative phone number OK Question Title * 14. Gender Male Female Non-binary/ third gender Prefer not to say Prefer to self-describe OK Question Title * 15. Please check as many races as you identify with from the list provided: American Indian/Alaskan Native Asian (including India, Pakistan, Philippine Islands) Black/African American (including Haiti) Hispanic Native Hawaiian/Pacific Islander (Including Guam and Samoa) White (including Middle East and North African) Other (please specify) OK Question Title * 16. If American Indian/ First Nation, what is your tribal affiliation? OK Question Title * 17. Marital Status Divorced Married Separated Single (never married) Widowed OK Question Title * 18. Are you a single parent and/or head of household? Yes No OK Question Title * 19. Are you a parent in a two-parent household? Yes No OK Question Title * 20. Do you receive TANF or CalWORKs benefits either for yourself or your dependent children? Yes No OK Question Title * 21. If yes, what kind of cash aid are you receiving? Tribal County I don't know OK Question Title * 22. Are you a legal permanent resident or a US citizen? Yes No OK Question Title * 23. Are you a California resident? (lived in CA for at least 12 months) Yes No OK Question Title * 24. Are you a US military veteran or dependent of a military veteran? Yes No OK Question Title * 25. Are you currently homeless or foresee being homeless in the future? Yes No OK Question Title * 26. Are you, or have you ever been a Foster Youth, Ward of the Court, or in Kinship/Guardianship care? Yes No OK Question Title * 27. Which best describes you? Received a high school diploma GED or passed the high school proficiency exam Current K-12 student Current college student I have an associate's degree I have a bachelor's degree None of the above OK Question Title * 28. What is your education goal? Associate's degree Certificate Transfer to a 4-year university Undecided Other (please specify) OK Question Title * 29. Have you attended any other colleges/universities? Yes No OK Question Title * 30. Was your high school GPA under 2.5? Yes No OK Question Title * 31. To the best of your knowledge, have either of your parents/legal guardians who raised you received a bachelor's degree? Yes No OK Question Title * 32. Are you currently enrolled at College of the Siskiyous? Yes No OK Question Title * 33. If so, how many units are you taking? OK Question Title * 34. Do you think you'd be interested in Disabled Student Programs and Services (DSPS)? Yes No OK Question Title * 35. By typing my name below, I: (i) certify that the information I have submitted is true, complete, and correct; (ii) authorize the above programs to record pertinent facts regarding my eligibility in the program, services rendered and post-secondary education enrollment; (iii) authorize the release of my student information for programs' needs; (iv) and understand that failure to fulfill any required student responsibilities may result in loss of services provided. By clicking on the 'I accept' below, I acknowledge and understand the about 'terms of agreement.' OK I ACCEPT