First Name

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* 1. First Name

Middle Initial

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* 2. Middle Initial

Last Name

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* 3. Last Name

COS ID

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* 4. COS ID

Date of birth

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* 5. Date of birth

Date / Time
Mailing Address

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* 6. Mailing Address

City

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* 7. City

State

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* 8. State

Zipcode

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* 9. Zipcode

Student email

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* 10. Student email

Personal email

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* 11. Personal email

Phone number

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* 12. Phone number

Alternative phone number

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* 13. Alternative phone number

Gender

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* 14. Gender

Please check as many races as you identify with from the list provided:

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* 15. Please check as many races as you identify with from the list provided:

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

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

Marital Status

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* 17. Marital Status

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

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

Are you a parent in a two-parent household?

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

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

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

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

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

Are you a legal permanent resident or a US citizen?

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

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

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

Are you a US military veteran or dependent of a military veteran?

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

Are you currently homeless or foresee being homeless in the future?

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

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

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

Which best describes you?

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* 27. Which best describes you?

What is your education goal?

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* 28. What is your education goal?

Have you attended any other colleges/universities?

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

Was your high school GPA under 2.5?

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* 30. Was your high school GPA under 2.5?

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

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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?

Are you currently enrolled at College of the Siskiyous?

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

If so, how many units are you taking?

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

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

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

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.'

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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.'

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