FAMILY BACKGROUND DATA
A.
Number of family members in your household: Number of your children:
Ages of your children:
Married
Separated Divorced Widowed
Marital Status:
Single
B.
Source of ŝncome͗
Employment Unemploym
ent Compsensation SSI
CalWORKS/TANF
Parents
C.
Ethnic Background;ĐŚĞĐŬĂůůƚŚĂƚĂƉƉůLJͿ
African American Middle Eastern (country)
American Indian/Alaskan Native
Pacific Islander (country)
Asian (country)
Filipino
White (Caucasian)
Other:
Hispanic, Latino, Chicano
EDUCATIONAL INFORMATION (Check all that apply)
A.
Educational Goals
Asso
ciates Degree Transfer to a 4-year college or university Certificate Undecided
Name of transfer college or university:
B.
Major:
C.
Did your parent(s) graduate ǁŝƚŚĂBĂĐŚĞůŽƌƐĚĞŐƌĞĞĨƌŽŵĂƵŶŝǀĞƌƐŝƚLJ?
Yes
No
D.
Is English the main language spoken in the home?
Yes
No If "No," what languages?
E.
Are you a high school graduate?
High School last attended:
Yes
No
Name
of High School: City/State or County
Date of Graduation:
F.
Did you receive a GED?
Yes No
If "
Yes," when did you receive your GED? Month Year
G.
Are you receiving Veterans Educational Benefits?
Yes
No
H.
Have you ever been a Dependent of the Court or a Foster Youth?
Yes
No
CERTIFICATION: Read this statement and sign below:
I hereby swear or affirm, under penalty, that all information on this form is true and complete to the best of my
knowledge. I also realize that any false statement or failure to give proof when asked, may be cause for exclusion
from participation in the EOPS program.
** I give the EOPS/CARE Program permission to print my name in EOPS publications (i.e. EOPS newsletters,
website, recognition programs) to recognize my accomplishments.
Yes
No
Student Signature: Date:
High School GPA:
How did you hear about EOPS?
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signature
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