Mt. SAC - Fresh Success Application

Intake Form

Participant Information: Information on this form will be kept confidential. It will be used to help you succeed and to measure how effective Fresh Success is. Please note items with an asterisk (*) are required pieces of information.

First name

Middle name

Last name

Other names used

What is your student ID?

What is your program or major?

Home phone number

Mobile phone number

Mailing address

City

Zip code

Contact preference

Gender

Male

Female

Other/ Decline to state

Social Security Number

We need this to check your CalFresh eligiblity with LA County.

Date of Birth

mm/dd/yyyy

Did you graduate from High School or receive a High School Equivalency certificate (such as the GED)?

Yes

Do you speak English as a second language?

Yes

Are you of Hispanic, Latino, or Spanish origin?

Hispanic or Latino

Not Hispanic or Latino

Which category best describes your race?

Please mark all that apply.

Assessment

Are you receiving assistance in any of the following areas from the college or another program?

Please mark all that apply.

Would you like information about any of the above services? Which?

What are your educational goals?

Do you plan to work in your career field as soon as you complete your community college degree or certificate?

*Planning to work after you complete your college education is required to be part of the Fresh Success Program

Yes

Are you currently working?

Yes, full time

Yes, part time

What are your short-term employment/job goals?

What are your long-term career/job goals?

Please list some of your strengths, skills, abilities, and/or interests that will help you reach your goals.

What gets in the way of accomplishing your goals?

CalFresh and Fresh Success

Are you currently receiving CalFresh?

Yes

If yes, in which County are you receiving benefits

Did you enroll in CalFresh, or do you plan to enroll in CalFresh, because of this Fresh Success opportunity?

Yes

Additional Information

Do any of the following describe you? (Mark all that apply)

* Note: If you were incarcerated, some career paths may offer fewer job opportunities. Please let us know your status so that we can help guide you to the most promising careers.

How many dependents do you have?

Consent for Release of Confidential Information

I consent to and authorize the release of my confidential information as listed below to Mt. San Antonio College; to provide and coordinate services, payments, and benefits or for other purposes authorized by law. I further grant permission to Mt. San Antonio College and the following agencies and their consultants to use my confidential information and disclose it to each other for these same purposes: the Foundation for California Community Colleges, the California Department of Social Services, the California Community College Chancellor’s Office, the County of Los Angeles Department of Public Social Services, the California Employment Development Department, and the U.S. Department of Agriculture Food and Nutrition Service. The confidential information I hereby release is limited to the following:  College records, such as enrollment and financial aid records, course completion records, academic progress records, educational placement tests, and educational plans  Fresh Success records, such as intake forms, participation records, career assessment results, and supportive services records  CalFresh and CalFresh Employment & Training records  Employment information as reported by my employers, including wages by quarter This authorization shall remain in effect as long as the records are needed for the reasons listed in the first paragraph of this form. I understand that I may withdraw this consent at any time in writing, but that will not affect any information already shared. A copy of this form is valid to give my permission to release confidential information under the terms of this consent. I hereby release and hold harmless all of the persons/organizations designated in this document from any and all liability and claims of any kind, related to the release, sharing, and use of information, as described in the foregoing, provided by any/all of the persons and organizations indicated. This release form has been read and reviewed with me and I understand its content. I understand that disclosing my social security number is voluntary but will be important in helping locate my employment records.

Agree

Signature

I certify that the above information is accurate. I agree to participate in the Fresh Success program if I am determined to be eligible for it.

By entering my full name, date of birth and checking the "I agree" box below I agree to this being taken as my consent in lieu of a signature

Agree

First and last name

Birthday

mm/dd/yyyy

Send me a copy of my responses

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