EOPS & CARE Application

EOPS & CARE Application
Application Date

MonthDayYear
Date
Program Acceptance Date

MonthDayYear
Date
Email
example@example.com
Name

First NameLast Name
900#
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Citizenship:

U.S. CitizenPermanent ResidentOther
Gender:

MaleFemaleOther/No response
Date of Birth

MonthDayYear
Date
Ethnicity:

American Indian/Alaskan NativeBlackAsianHispanic/LatinoWhiteNative Hawaiian/Pacific IslanderMore than one raceNo response
What language is spoken in your home?
PARENT'S EDUCATION

Parent's Education:Please only list the parent(s) whose household you grew up in.
Father's Education

Less than high school completedGEDHigh school graduateSome high schoolCollege degree (B.A. or B.S.)Graduate or professional degree
Mother's Education

Less than high school completedGEDHigh school graduateSome high schoolCollege degree (BA or BA)Graduate or professional degree
FINANCIAL INFORMATION
Martial Status:

SingleMarriedDivorced/Separated
Are you receiving TANF/Cash Aid?

YesNo
Do you have any dependents?

YesNo
If yes, how many and what are their ages?
Did anyone claim you as a dependent on his or her tax return last year?

YesNo
Did you file a tax return for last year?

YesNo
Number of people in your household (This includes anyone on your tax forms as part of your family unit)
If you are a dependent student, list both yours and your parent(s) income together.
If you are a independent student, list both yours and your spouse's income together.
REQUIRED PAPERWORK

1) Board of Governor's Grant (BOG) aka California Promise Grant printout 2) Student Detail Schedule printout
Are you receiving Financial Aid from Feather River College?

YesNo
Do you have a disability? (Physical, learning, and/or psychological)

YesNo
Do you have documentation regarding your disability?

YesNo
Do you think your disability will affect your ability to participate in educational experiences at FRC?

YesNo
EDUCATIONAL INFORMATION & GOALS
High School Attended
GPA
Diploma Type

DiplomaGEDNone
Date Received

MonthDayYear
Date
Any degrees or certificates your currently possess
Your major or career interest
What degree do you wish to acquire?

Associate's DegreeBachelor's DegreeMaster's DegreeDoctorateProfessional Degree
EMPLOYMENT STATUS
Are you currently employed?

YesNo
If yes, how many hours per week?
If determined eligible for EOPS Program, I agree to comply with the following conditions:

You must sign "Mutual Responsibility Contract"

You must complete a Progress Report each semester and if the progress report shows that you are dropping below a 2.0 GPA in any course you will need to accept a tutor for that class.

You must attend an Orientation each sememster or view the online presentation

You must maintain at least 12 units

You must maintain at least a 2.0 GPA

You must follow your Student Educational Plan (SEP) agree to with your EOPS Counselor or Advisor

You must meet with your EOPS personnel at least three times each semester
CONFIDENTIALITY & STUDENT RELEASE OF INFORMATION

EOPS handles student information confidentially. EOPS will use this information to verify your program eligibility to the Federal Government and to provide you with personal and academic services that may occasionally require the use of your personal information fro additional research. Your signature below verifies your full agreement and understanding of this application.
- I authorize EOPS to: obtain disability data, financial aid documents, transcripts and assessment scores; verify citizenship and academic standing in order to provide EOPS services for me.
- I certifiy that the information I ahve given is cirrect to the best of my knowledge. I understand that if any information is found to be false, my eligibility for EOPS services wil be jeopardized.
Student Signature
Date

MonthDayYear
Date
EOPS Signature
Date

MonthDayYear
Date
Should be Empty:

EOPS & CARE Application

PARENT'S EDUCATION

FINANCIAL INFORMATION

REQUIRED PAPERWORK

EDUCATIONAL INFORMATION & GOALS

EMPLOYMENT STATUS

CONFIDENTIALITY & STUDENT RELEASE OF INFORMATION