EOP&S Application
Name: _________________________________________________________________
Coastline College ID#: _________________________________
Address: ______________________________________________________________
Home Phone: ___________________________________________
City / Zip: ____________________________________________________________
Cell Phone: ______________________________________________
First
Middle
Last
Gender: Male ☐ Female ☐
Email Address (print neatly): _____________________________________________________________________________________________________________
Date of Birth: ________________________________________________________
Educational Goal:
Ethnic
Background:
(Check
appropriate box)
☐ AA or AS degree
☐ Transfer to University
☐ Career/Technical Certificate
☐
African
American /
Black
☐
☐
Anglo/
White
Asian /
Pacific
Islander
Eligibility for Program and Services:
1. Are you a U.S. Citizen? ☐ Yes ☐ No
2. Are you a California resident? ☐ Yes ☐ No
3. If “NO” are you eligible for AB540? ☐ Yes ☐ No
4. How many units are you planning on taking this semester?
Circle: 12 or more / 9 – 11 / below 9
5. Have you applied for the Board of Governors’ Waiver and/or
FAFSA? ☐ Yes ☐ No
6. Total Coast Community College District units completed
(Coastline, Golden West, Orange Coast colleges): _______
7. What is your cumulative GPA: ___________
Educational Assessment:
1. Have you taken the Math placement test:
☐ Yes ☐ No
If “YES” did you assess in Math 010 or lower:
☐ Yes ☐ No
2. Have you taken the English placement test:
☐ Yes ☐ No
If “YES” did you assess in English 99 or lower:
☐ Yes ☐ No
Intended Major: _____________________________________
Intended Minor: _____________________________________
☐
☐
☐
☐
Hispanic /
Latino
American
Indian /
Alaska Native
Vietnamese
Other:
___________________
3. High School Graduation Status:
4.
5.
6.
7.
8.
9.
☐ Graduate - Date: _____ / _____ / __________
☐ Certificate of Proficiency
☐ Non-graduate
☐ G.E.D.
High School Grade Point Average: _____________
Have you ever been enrolled in remedial classes:
☐ Yes ☐ No
☐ High school remedial
☐ High school ESL
☐ Adult Education ESL
☐ College remedial courses
☐ College ESL
Did either of your parents graduate from a 4-year
college/university: ☐ Yes ☐ No
Is your primary language spoken at home English?
☐ Yes ☐ No
Do you have a diagnosed learning disability?
☐ Yes ☐ No
Are you an current or former foster youth? ☐ Yes ☐ No
10. What age(s) were you when you were in foster care?
______________________________________________________________
CERTIFICATION
I certify that the above is factual and correct. I grant Coastline Community College EOPS/CARE/CAFYES office the authority to
verify and/or obtain the records necessary to confirm the above information from schools and/or agencies. I also understand
that it may be necessary to provide further documentation to determine my eligibility for the EOPS/CARE/CAFYES program
Student Signature: ___________________________________________________________
Date: ______________________________
FOR PROGRAM STAFF ONLY
Assessment Level: Math _________ English _________ ESL _________
BOGFW: A________ B_________ EFC_________
Accepted: ________ Denied: _________
Staff Signature: _____________________________________________________
California Resident: _____ Yes ______ No
AB540: ______ Yes _______ No
Foster Youth: ______ Yes _______ No
Date: ___________________________________________
Director Signature: _________________________________________________
Date: ___________________________________________
CARE Application
CARE (Cooperative Agencies Resources for Education) is a supplemental program for EOP&S eligible students who
are single head of household with a family member who is a recipient of CalWORKs/TANF and has a child who is
under 14 years of age. If you are eligible for the CARE program you may receive benefits that are in addition to those
you receive as an EOP&S participant. Additional paperwork will be required.
Student Name: ___________________________________________________________
Date: ______________________________
Are you at least 18 years of age? ☐ Yes ☐ No
Are you or your dependent children who live with you receiving cash aid from the Department of Social
Services? ☐ Yes ☐ No
Case number with DSS: ________________________ Date benefits started: ________________________________________
Marital Status: (Please check one):
☐ Married
☐ Single
☐ Divorced
☐ Widowed
☐ Separated
☐ Married (spouse absent)
Family Status (List all family members that currently live with you)
Name
Relationship
Self
Age
Date of Birth
Proof of any child under 14 years of age will be required from DSS.
Proof of single head of household will also be required.
To remain in good standing with the CARE Program you must agree to the following:





Meet with the CARE staff at least twice each month.
Participate in any special CARE activities as required.
Enroll in at least 12 units at Coastline Community College.
Provide an annual verification of eligibility (Notice of Action) from DSS at or before the start of a semester.
Notify the EOP&S/CARE office if there is any change to your status with DSS, change in marital status, or
other issues that my have an impact on your eligibility.
CERTIFICATION
I certify under penalty of perjury that all information stated above is true and complete to the best of my knowledge.
I realize that any false statements or failure to provide proof when requested may be cause for denial, reduction,
withdrawal and or repayment of my grant. I grant Coastline Community College EOPS/CARE office the authority to
verify and/or obtain the records necessary to confirm the above information from any appropriate agency.
Student Signature: ___________________________________________________________ Date: ______________________________