Please note the following:

• To receive childcare or transportation support, you must have monthly appointment/check-ins with CPI Director.

Completing the Career Pathways Intake Checklist is required for all Pathways students prior to receiving ANY financial assistance from CPI.

I understand (INITIAL EACH STATEMENT):

AN APPLICATION WILL NOT BE CONSIDERED UNTIL ALL DOCUMENTATION HAS BEEN SUBMITTED TO THE CPI STAFF. IF YOU HAVE QUESTIONS OR NEED ASSISTANCE, PLEASE ASK.

EQUAL OPPORTUNITY STATEMENT -- SouthArk does not discriminate on the basis of age, race, color, creed, gender, religion, marital status, veteran’s status, national origin, disability, or sexual orientation in making decisions regarding employment, student admission, or other functions, operations, or activities.

The college is in compliance with Titles VI and VII of the Civil Rights Act of 1964; Title IX of the Educational Amendments of 1972; Section 504 of the Rehabilitation Act 1973; and the Americans with Disabilities Act of 1990 (ADA), and all other federal and state laws related to equal opportunity practices.

Those having questions or seeking information regarding the college’s compliance with and implementation of the aforementioned regulations should contact:

Equal Opportunity Officer c/o Human Resources

South Arkansas College

300 South West Ave.

El Dorado, AR 71730

(870) 862-8131, 1-800-955-2289

Please read and complete entire application.

Please list ALL children’s name and social security numbers:

                            

Arkansas Career Pathways Initiative

RESPONSIBILITY AGREEMENT

REVISED 08/22/2024

As a participant in the Career Pathways Initiative, you are eligible to receive services and participate in activities that will increase your chances of succeeding academically and graduating. These services are offered at no additional cost beyond your regular tuition and fees as a South Arkansas College student. The program and staff will make this commitment to you.  In return, we ask that you make the following commitment to us:

1. I accept responsibility for my own academic success and agree to attend classes regularly. I understand that I am to maintain satisfactory class attendance (as listed in the course syllabi).
2. I understand that the Career Pathways staff may confer with my instructors at any time concerning my attendance, my progress, and my grade. However, it is my responsibility to get my attendance form signed by my in-class instructors each month and to send an e-mail to my online instructors requesting a progress report be sent to CPI Staff. I have been advised to copy CPI Staff on these e-mails.
3. As a new CPI participant, I agree to complete Career Pathways Orientation on Blackboard.
4. As a new CPI participant, I agree to sign up for Remind Messaging App.
5. I agree to attend an initial advisement session with my Career Pathways counselor at the beginning of each semester.  It is my responsibility to schedule and keep an appointment with my counselor at least once per month to discuss progress.
6. I agree that if I miss appointments for two consecutive months will result in no assistance for the semester.
7. I understand that my child (ren) cannot be brought to appointments with the Career Pathways staff.
8. I understand that any financial assistance offered by the Career Pathways Initiative is based on an “as needed” situation that will be determined by the Career Pathways staff, and that services are not an entitlement.
9. I understand that I may receive CPI services at the same time that I am receiving other services (WIOA, Pell, Rehab, etc.) as long as the services are different.  Example 1:  If I am getting a transportation stipend from CPI, I should not get a mileage check or any other form of transportation assistance from another provider.  Example 2:  If I have WIA and am using that money to purchase textbooks, I will not be eligible for book assistance from CPI. Example 3: There is no problem if I use WIA funds to purchase textbooks and CPI pays my tuition.
10. I agree to take any/all assessments necessary:  Interest Profile/TABE/Accuplacer/Job Readiness Assessment.
11. I agree to complete at least 2/3 of my course load taken each semester.
12. I agree to attend tutoring sessions in the Learning Center if an Early Alert is issued by my instructors.
13. I agree to participate in career exploration, financial aid advisement, counseling, academic advising, and workshops as advised by Career Pathways staff.
14. I authorize the Career Pathways staff at South Arkansas College to obtain or exchange any records or data from the Student Records Office, Financial Aid Office, and /or any public service agency pertinent to my participation in the Career Pathway Initiative.  I understand that my records are treated confidentially.
15. I agree to advise the Career Pathways staff of any change of address, phone number, or school/employment status within 5 working days.
16. I understand that if my semester grade point average drops below a 2.0, the services that are offered to me will be discontinued.
17. I agree that Career Pathways will not pay my tuition for repeated courses.
18. I understand that StudentLingo workshops are required monthly, and if I fail to complete at least 1 workshop each month, CPI benefits (i.e., transportation, childcare, and laptop program) will be suspended.
19. If I fail to comply with the above obligations and responsibilities, I understand that I will be dismissed from the Career Pathways Initiative.

 

AUTHORIZATION TO RELEASE OR OBTAIN INFORMATION FOR THE CAREER PATHWAYS INITIATIVE
 

In the course of providing the best possible service to the participants of the Arkansas Career Pathways Initiative Program, the exchange of information between governmental agencies and educational institutions may be necessary. I hereby authorize the Arkansas Career Pathways Initiative personnel to release and/or provide, on a need to know basis, information which is reasonably necessary to accomplish the goals and objectives of the Pathways program. I understand the individuals that receive and use this information will hold it in the strictest confidence and will use it to better serve me. Non-personally identifiable information can be shared by ADHE/CPI with other entities to promote the program both inside and outside the state. I understand copies of this signed release will serve as valid authorization and the original signed document will be kept in my file. I understand that government records may be used to obtain this information.

I hereby authorize release of the following information to the following agencies, institutions or other parties unless the release or provision of such information is otherwise prohibited by law or regulation (PLEASE INITIAL BY EACH STATEMENT):

As a condition to my authorization the Arkansas Career Pathways Initiative agrees to use the information obtained solely for the purposes authorized by law and regulation including determining eligibility for employment and training programs, developing an appropriate employment or self-sufficiency plan, educational training and plans, and helping me achieve my occupational and education goals. This authorization can be revoked at any time with a written statement from me. This authorization is valid for the purpose of obtaining information for program performance reporting and participant follow-up activities related to pre-participation and post exit employment and earnings and for the purpose of obtaining educational information relating to my participation in the Career Pathways Initiative. I understand that, as a condition of my receiving services, information collected by the Career Pathways Initiative will be used for purposes of determining overall program performance.

This agreement outlines the responsibilities and expectations of a student in the Career Pathways program. Additional policies and procedures related to what is outlined below can be found in the CPI
Student Handbook.

• I will maintain eligibility requirements. I will notify CPI of any address changes, enrollment status
changes, dependent’s status, or other eligibility requirements within 30 days of the change.
• I will comply with all required office visits, attendance verification, workshops, monitoring and
work verification as outlined in the CPI Student Handbook, including agreeing to a case
management plan. I will also comply with all requirements of the college student handbook.
• I will maintain good academic standing as defined by the CPI Student Handbook, including a 2.0
GPA. If my grades fall below 2.0 GPA, I understand that I may be placed on CPI probation which
may affect the level of financial support I receive.
• I will follow the chosen degree path as decided in my case management plan. Any changes from
that path must be approved prior to continued CPI assistance.
• I will use resources and assistance provided in a responsible and respectful manner and in
accordance with federal program guidelines.
• I understand that the goal of CPI is for me to go to work upon graduation.
• I agree to a variety of communication methods including email, phone call and text.
• I authorize CPI staff to contact my employer for documentation of work as needed.

This agreement is valid from the date signed to date of withdrawal from the CPI program and until employment tracking requirements are complete. Either party may terminate participation in the program with written notice. Grounds for termination may include but are not limited to failure to meet program expectations, code of conduct issues, or funding constraints.

By signing below, I acknowledge that I have read, understand and agree to the terms outlined in the agreement and have been given a copy of the CPI Student Handbook.

  Release Form

I hereby grant the Arkansas Division of Workforce Services and/or the Temporary Assistance for Needy Families Program (TANF) permission to use my likeness in a photograph, written story, or video in any and all of its publications, including Web site entries, without payment or any other consideration.

I understand and agree that these materials will become the property of the Arkansas Division of Workforce Services and/or the Temporary Assistance for Needy Families Program and will not be returned.

I hereby irrevocably authorize the above named agency(s) to edit, alter, copy, exhibit, publish or distribute this photo, story, or video for purposes of publicizing the Arkansas Division of Workforce Services and/or the Temporary Assistance for Needy Families Program, or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness or story appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph, story, and/or video.

I hereby hold harmless and release and forever discharge the Arkansas Division of Workforce Services and/or the Temporary Assistance for Needy Families Program from all claims, demands and causes of action that I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have, or may have, by reason of this authorization.

I am 21 years of age and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.

•    If checked, the applicant is eligible for TANF-funded services. Complete Steps 2 and 4. 

•     If not checked, complete Step 2 AND Step 3 to verify eligibility and parental status using income

Child: a dependent person under 21 who has never married or whose marriage was annulled.
Parent: includes a mother, father, adoptive mother, adoptive father, step-father and step-mother.
Noncustodial Parent: the parent is not in the household of the child (see definition of child above). Both the noncustodial parent and the child must live in the State of Arkansas.
Blood Relative: including those of half-blood, within the relationship of siblings, first cousins, nephews, nieces, aunts, uncles and individuals of preceding generations as denoted by prefixes of grand, great, great-great, etc. This group includes relatives within the fifth degree of kinship to the dependent child;
therefore, this includes first cousins once removed, but not the second cousins.

If Step 1 OR 3, AND 2 are not checked, STOP. The applicant is NOT eligible for TANF-funded services.
If Step 1 OR 3 AND 2 are checked, go to Step IV

If Step 1 OR Step 3 AND Step 2 AND 4 above are checked, the appliant is eligible for TANF-funded services.
Go to Section III.

2025 Federal Poverty Guidelines

250% of the Federal Poverty Level

Family Size	Annual Income	Monthly Income	If family size is more than 8, add an additional $13,750 per additional family member.
1	$39,125	$3,260
2	$52,875	$4,406
3	$66,625	$5,552
4	$80,375	$6,698
5	$94,125	$7,844
6	$107,875	$8,990
7	$121,625	$10,135
8	$135,375	$11,281

• If YES, the applicant is eligible for CPI services. If NO, the family is not eligible based on earned income unless receiving services listed in Step 1.

Applicant Certification

I certify to the best of my knowledge that the information in this form is true, including income and citizenship/qualified non-citizenship information.