Application for Student Support Programs 3/1/19 - 4/30/19

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* 1. First Name

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* 2. Middle Initial

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* 3. Last Name

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* 4. COS ID

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* 5. Date of birth

Date / Time

Date

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* 6. Mailing Address

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* 7. City

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* 8. State

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* 9. Zipcode

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* 10. Student email

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* 11. Personal email

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* 12. Phone number

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* 13. Alternative phone number

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* 14. Gender

Male

Female

Non-binary/ third gender

Prefer not to say

Prefer to self-describe

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* 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)

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* 16. If American Indian/ First Nation, what is your tribal affiliation?

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* 17. Marital Status

Divorced

Married

Separated

Single (never married)

Widowed

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* 18. Are you a single parent and/or head of household?

Yes

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* 19. Are you a parent in a two-parent household?

Yes

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* 20. Do you receive TANF or CalWORKs benefits either for yourself or your dependent children?

Yes

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* 21. If yes, what kind of cash aid are you receiving?

Tribal

County

I don't know

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* 22. Are you a legal permanent resident or a US citizen?

Yes

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* 23. Are you a California resident? (lived in CA for at least 12 months)

Yes

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* 24. Are you a US military veteran or dependent of a military veteran?

Yes

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* 25. Are you currently homeless or foresee being homeless in the future?

Yes

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* 26. Are you, or have you ever been a Foster Youth, Ward of the Court, or in Kinship/Guardianship care?

Yes

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* 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

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* 28. What is your education goal?

Associate's degree

Certificate

Transfer to a 4-year university

Undecided

Other (please specify)

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* 29. Have you attended any other colleges/universities?

Yes

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* 30. Was your high school GPA under 2.5?

Yes

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* 31. To the best of your knowledge, have either of your parents/legal guardians who raised you received a bachelor's degree?

Yes

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* 32. Are you currently enrolled at College of the Siskiyous?

Yes

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* 33. If so, how many units are you taking?

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* 34. Do you think you'd be interested in Disabled Student Programs and Services (DSPS)?

Yes

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* 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.'