Career Pathways Application

Career Pathways Initiative

Application Packet
INITIAL DOCUMENTATION

REQUIRED FOR ARKANSAS CAREER PATHWAYS OFFICE
Make sure to have these documents to upload with applications. These documents are required to complete your application

TABE/Accuplacer/ACT ScoresCopy of Latest Federal Income Tax Return TRANSCRIPTCopy of Child(ren)'s Birth Certificate(s)Copy of Child(ren)'s Social Security Card(s)Copy of Applicant's Driver's LicenseCopy of Applicant's Social Security CardCopy of High School/GED AND College TranscriptLetter from DHS office Verifying Benefits currently received - TEA, Food Stamps, Medicaid, and/or ARKidsProof of FAFSA Application and/or Copy of any Financial Award Letters, if Applicable
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):
That Career Pathways is not an entitlement program. Even though an individual may meet the basic criteria for eligibility, the CPI staff must determine if the program is the appropriate entity to provide services for me.*
That completing this application does not guarantee that you will be approved for the CPI program.*
That my appointment with the CPI Director will NOT be scheduled until ALL DOCUMENTATION requested above has been turned in to the CPI Office.*
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.
Applicant Signature*

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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

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.
Signature of Student*

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Date*

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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):
The Department of Human Services and the Division of Child Care and Early Childhood Education (DHS/DCCECE) may provide information regarding my participation in agency programs. This will include names, social security numbers and other necessary information pertaining to my children.*
The Department of Workforce Services( DWS ) may provide information regarding my participation in the Transitional Employment Assistance (TEA) program, unemployment insurance benefit program and my participation in Workforce Investment Act employment and training programs *
The Department of Career Education may provide information including WAGE, Adult Education and current and past education participation.*
The Arkansas Department of Higher Education and affiliated educational institutions may provide records relating to my current and past education.*
The educational institution involved in my participation in the Career Pathways Initiative may provide information between the internal departments. *
The Workforce Investment Act service provider may provide information regarding my participation in adult work programs.*
The Division of Rehabilitation Service may provide information regarding my participation in Rehabilitation Services employment and training programs. *
The Department of Education and local school districts may provide information regarding my current and past education.*
Private and career training institutions may provide records relating to current and past training and education.*
My current and past employers may provide information related to my employment*
My likeness may be used for public relations purposes in the media including newspapers, newsletters, TV ads, and other media venues.*
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.
Student's Signature*

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Print Name*
Date*

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Release Form
I, First Name* Last Name* hereby agree and consent to allow the Arkansas Department of Education (ADE), and anyone authorized by ADE, to use the name, school district, and hometown and to reproduce, edit, alter, or publish photographs, audio, and video recordings of my child, children, or myself and their/my work products (“my/child’s information”) without payment or any other consideration.

I understand that the ADE owns a copyright and all other media distribution rights for any publication in which my/child’s information appears and may exclusively use this in any manner, in whole or in part, including print, broadcast, digital media, or online. I understand that publications containing my/child’s information will become property of ADE and will not be returned.

Furthermore, I, on behalf of myself, my child or children, and any person acting on our behalf, herby consent and agree to release any and all claims or causes of action against ADE and any of its associates, employees, or agents associated with the release of my/child’s information that is in the possession or control of ADE and is used or released as part of the normal course of business of the ADE.
Parent's Name or Adult (PLEASE PRINT)*
Child’s Name or Children’s Names (PLEASE PRINT)*
Signature of Parent or Adult (Please sign in cursive.)*

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Date*

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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.
(Typed Name of Participant)*
Student's Name
Signature of Participant*

Clear
(Typed Name of Case Manager)*
LaBreshia Hicks
If the participant signing is under age 21, there must be consent by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of First Name* Last Name* , named above, and do hereby give my consent without reservation to the foregoing on behalf of this person.
(Typed Name of Guardian
Student's Name
Signature of Parent/Guardian

Clear

ELIGIBILITY FORM FOR TANF FUNDED SERVICES

(For use by Career Pathways Initiative)
SECTION I: APPLICANT IDENTIFICATION
Full Name:*
First & Last Name
Address:*
Phone:*
City:*
Zip Code:*
SSN:*
Date of Birth*

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SECTION II: ELIGIBLITY
STEP 1: Categorical Eligibility (check the area that apply.)*

Transitional Employment Assistance (TEA) (current or former)Supplemental Nutrition Assistance Program (SNAP)Medicaid or CHIP (including ARKids)Other
• If checked, the applicant is eligible for CPI and no further income verification is needed. A letter of eligibility or other official documentation should accompany this form and be placed in the student file. Go to Section III.

• If not checked, complete Step 2 AND Step 3 to verify income eligibility ad parental status.
STEP 2: Child

The applicant is a custodial or noncustodial parent or adult caretaker of a child under the age of 21 .
STEP 3: Income Eligibility (Review the income chart and complete the Financial Eligibility Section.)

Family income is less than 100% of the Federal Poverty Level (STOP: Advise applicant to apply for TEA benefits.)Family income is between 100% and 250% of the Federal Poverty Level.
STEP 4: Citizenship Eligibility (Check which applies.)

Citizen of the United StatesNon-citizen who meets the TANF-eligible citizen criteria.
•       If neither box is checked, the applicant is NOT eligible for TANF funded services or programs including CPI.

o   If Step 1 is checked, the applicant is eligible for TANF/CPI services. Go to Section III.

o   If Step 3A is checked, STOP and refer the applicant for TEA services.

o   If Step 2 AND 3B AND 4 are not checked, STOP. The applicant is not eligible for TANF-funded services. Got to Section IV.

FAMILY INCOME WORKSHEET – Eligibility for TANF/CPI Funded Services

Federal Poverty Guidelines

Family Size	Annual Income	Monthly Income	Weekly Income	If family size is more than 8, add an additional $5,380 per family member.
1	$37,650	$3,138	$724
2	$51,100	$4,258	$983
3	$64,550	$5,379	$1,241
4	$78,000	$6,500	$1,500
5	$91,450	$7,621	$1,759
6	$104,900	$8,742	$2,017
7	$118, 350	$9,863	$2,276
8	$131,800	$10,983	$2,535

Family Information
Family size: (number of adults and minor children in the household.

Household Members: List all people who live in the home, including the applicant.

	SSN	Full Name (first, middle, last)	Birth Date	Relationship to Applicant
Applicant
Household Member
Household Member
Household Member
Household Member
Household Member
Household Member

Family Income
Total annual family earned income is
(earned from employment and before taxes)
Is this amount less than 250% of FPL on the above chart?

YesNo
• If YES, the applicant is eligible for CPI services. If NO, the family is not eligible based on earned income.
SECTION III: DETERMINATION OF NEED
The services being provided are to:*

To provide assistance so that children may be cared for in their own homes or the home of a relative.To end dependence of parents on government assistance by promoting job preparation, work or marriage.(This is the stated objective of CPI.)Prevent or reduce out-of-wedlock pregnancies.Encourage the formation and maintenance of two-parent families.

SECTION IV: CERTIFICATION OF ELIGIBILITY CRITERIA
This is a certification that the information provided on this form is true and correct to the best of the knowledge of those individuals whose signatures are affixed. If the information changes, the applicant will notify the CPI staff. CPI is to review and check off the following statements with the CPI applicant.*

I understand that I am required by law to provide my Social Security Number or proof that I have applied for a Social Security Number if I do not currently have one to receive TANF funded benefits/services. This is mandatory under the Social Security Act (42 U.S.C. 1137). The Social Security Number is used to administer the program, including determining eligibility, attributing the receipt of services, correspondence and participation to my case, as well as for reporting purposes.I do not have a Social Security Number and do not know how to apply for one, I understand that CPI will refer me to the appropriate agency and may provide other help as appropriate.I understand that my Social Security Number will be used to associate all records to my identification, including program participation and the receipt of services and benefits.
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.
Phone:*
Street/PO:*
City/State/Zip:*
Date of Birth:*

MonthDayYear
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SSN:*
Email:*
example@example.com
Signature:*

Clear
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INITIAL DOCUMENTATION REQUIRED FOR ARKANSAS CAREER PATHWAYS OFFICE

Please upload all required documents
TABE/Accuplacer/ACT Scores

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Copy of Latest Federal Income Tax Return TRANSCRIPT*

Retrieve this from www.irs.gov
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Copy of Child(ren)'s Birth Certificate(s)*

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Copy of Child(ren)'s Social Security Card(s)*

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Copy of Applicant's Driver's License*

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Copy of Applicant's Social Security Card*

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Copy of High School Transcript and College Transcript if Applicable*

High School Transcripts are REQUIRED
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Letter from DHS office Verifying Benefits CURRENTLY Received - TEA, Food Stamps, Medicaid, and/or ARKids*

*Must be current letter - within the same month of application
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Proof of FAFSA application and/or Copy of any Financial Aid Award Letters, if Applicable*

*financial aid is required to be filed
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Should be Empty:

Career Pathways Initiative

INITIAL DOCUMENTATION

ELIGIBILITY FORM FOR TANF FUNDED SERVICES

SECTION I: APPLICANT IDENTIFICATION

SECTION II: ELIGIBLITY

FAMILY INCOME WORKSHEET – Eligibility for TANF/CPI Funded Services

Family Information

Family Income

SECTION III: DETERMINATION OF NEED

SECTION IV: CERTIFICATION OF ELIGIBILITY CRITERIA

INITIAL DOCUMENTATION REQUIRED FOR ARKANSAS CAREER PATHWAYS OFFICE