Number in household Number in Total Family Income Last year. (Including yourself ) (adjusted gross income and/ or untaxed income) 1 $ 15,315 or less 2 $20,535 or less 3 $25,755 or less 4 $30,975 or less   Add $5,220 or each additional dependent
Gavilan College  EOPS/CARE Application
[_] Fall	[_] Spring	[_] Summer	[_] Year

Address __________________________________ City ____________________ ZIP ________________

Phone # (      ) _______________________ Birth date_____/______/______    (     ) Male      (    ) Female

PLEASE CHECK ONE IN EACH OF THE FOLLOWING CATEGORIES:
AGE: Under 18 [ __ ] 18-25 [ __ ] 26-35 [ __ ] 36+ [ __ ]
Marital Status: Single [ __ ]Married [ __ ] Separated [ __ ] Divorced [ __ ]

PREDOMINANT ETHNIC BACKGROUND (SELECT ONE)
White, not Hispanic[ _ ] #9; #9; #9; Native American or Alaskan Native [ __ ]
African American [ __ ] #9; Filipino [ __ ] Hispanic [ __ ] #9; #9; #9; #9; #9; Other (Specify) ________________________
Asian or Pacific Islander [ __ ]

EDUCATIONAL BACKGROUND
(     ) High School Diploma    (    ) GED    (     ) Non-Graduate                 Parent's native language____________         
Highest educational level of mother _________________Highest educational level of father_____________

GAVILAN STATUS:       NEW_____       CONTINUING_____      RETURNING_______

EDUCATIONAL GOAL (SELECT ONE)
(    ) AA/AS degree             (    ) Transfer with an AA/AS degree             (    ) Transfer without AA/AS degree
(    ) Certificate/License    (    )Job Skills
Transfer institution _________________________________ Major ____________________________

Have you attended any other colleges?  (    ) Yes    (    ) No If yes, list name of college(s)_________________
 

OTHER:
Total family income last year___________________       Have you applied for Financial Aid?  (    ) Yes  (    ) No
Number in household___________________                     What date did you begin living in CA?  _________

FOR CARE ELIGIBILITY ONLY:
Are you a single parent on CalWORKs/TANF with a child under 14 years of age?  (    ) Yes  (    ) No
If yes, answer the following:
Single Parent, Head of Household? (   ) Yes  (   ) No    Are you, or your children receiving CalWORKs? (  ) Y  (  ) N
Date started receiving CalWORKs____________  Are you a participant of the CalWORKs Program?  (  ) Y  (  ) N
Number of dependent children_______Age of youngest child______Date of birth of youngest child_________
 

Student signature_____________________________________________      Date_____________________

Education Criteria for Title V
Not qualified for enrollment into minimum level English or math applicable to associate degree English 250 or math 205). ESL students not required to take college placement test.

1. Did not graduate from high school or obtain GED.
2. Graduated from high school with GPA of 2.5 or lower on a 4.0 scale.
3. Previously enrolled in remedial education (list classes below).
4. Other factors set forth in district's plan submitted to Chancellor pursuant to section 56270 as follows:

1. First in family to graduate from college______________________________
2. Member of underrepresented student group __________________________
3. Primary language spoken in home is not English ______________________
4. Emancipated Foster care youth ____________________________________

College transcripts on file _____ Requested _____ High School transcript on file _____ Requested_______

College units completed __________________ Financial Award letter on file _____ Date __________

College remedial classes_________________________________________________________________