Miramar College CalWORKs Student Services Application
Welcome to CalWORKs Student Services at Miramar College!  

To make thinks a little easier during our global crisis, we are temporarily collecting your application for our program using Google Forms.  Providing the information requested below will help us serve you better.

After you complete this application, we will verify your status with the County Welfare to Work Employment Case Management system and will contact you to schedule an orientation to receive services from our program.  

We will provide your services remotely using Zoom video-conferencing technology.  
>>Links to tutorials on how to access Zoom are at the end of this application.  
>>You will receive an email with the information you completed on this application, including links to the Zoom tutorials.

Please note that due to the Family Educational Rights and Privacy Act (FERPA):
1.  we may only communicate directly with the student (and not the spouse or other family members of the student).  
2.  This application needs to be completed and signed by the student.

Please be informed that FERPA is a Federal law that protects student privacy of educational records:
 https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html

If Farsi language assistance is needed, we can arrange for language support by one of our team members.

For more information and updates about our program, please visit our website: https://www.sdmiramar.edu/campus/calworks
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Email *
Last Name *
First Name *
Gender *
Required
Your Student ID Number *
Your Zip Code *
Your Phone Number *
Do we have permission to leave you a detailed message at this phone number? *
Your County Case Number *
Do you currently receive Cash Aid for yourself AND your children? *
Approximately what date did your Cash Aid benefits begin (month and year is adequate)? *
Did you graduate from High School or complete the equivalency? *
Required
Have you already completed a Bachelor Degree or higher? *
Where did you complete your Bachelor or other higher degree and in what subject?  In what major or subject did you complete your degree?  (This information will help us prepare the best counseling we can provide you!)
Please help us understand your Ethnicity or National Origin.   (This information helps us understand and advocate for the diversity needs of the students in our program.) *
Required
What is your native language? *
What other languages do you speak?
Please help us understand your family composition. *
Required
Please help us understand a little more about your situation. *
Required
How many children do you have (including adult children and children not in your custody)? *
How many of your children are on your County welfare case? *
How many children are under the age of 6? *
Do you have any children under the age of 2? *
Are you on a New Young Child Exemption? *
Are you on a Temporary Medical Exemption? *
Do any of your children have special needs or disabilities? *
Which office provides your Welfare to Work Employment Case Management services? *
Required
Please enter the full name of your Employment Case Manager (ECM) or Employment Training Advisor (ETA)
Please enter your Employment Case Manager's (ECM) or Employment Training Advisor's (ETA)--EMAIL ADDRESS.
Please enter your Employment Case Manager's (ECM) or Employment Training Advisor's (ETA)--phone number.
What is your Career or Employment Goal? *
What "majors" or subject areas are you interested in studying? *
What is your educational goal for attending San Diego Miramar College?  (please check all that apply to you) *
Required
We would like you to learn about additional Student Services on campus to help you succeed.  Please select the services below you think you may need. *
Required
Are you currently employed? *
Required
Please tell about the kind of work do you do.
How did you hear about our program?  Who referred you to our college? *
Required
AUTHORIZATION TO RELEASE INFORMATION:  By checking the box below, I give my permission for any Miramar College CalWORKs Student Services Counseling or Administrative staff to communicate with:  (1) the County of San Diego Health and Human Services Agency (and their representatives); AND (2) my assigned Welfare to Work Employment Case Management Agency (Public Consulting Group or ResCare) and their staff.  I understand that the purpose of this communication is to provide information relevant to my Welfare to Work Plan, to access necessary Supportive Services, and to aid resolution to challenges I may experience while receiving benefits in the County CalWORKs system. *
Required
ATTESTATION:  I understand that the information I provided on this application will be used to determine my eligibility for the San Diego Miramar College CalWORKs Student Services Program.  By ENTERING MY FULL NAME BELOW, I also certify that this information is true and accurate to the best of my knowledge. *
By selecting the choices below, I am receiving information about how to access Zoom video-conferencing technology for future appointments with the Miramar CalWORKs Student Services program.  I understand that Zoom is a web-based, meeting platform, and when I schedule appointments with this program, I will receive a specific Zoom link for my appointments. *
Required
A copy of your responses will be emailed to the address you provided.
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