CalWORKs Release of Information

Student B Number

Case Number

This form authorizes the Barstow Community College CalWORKs staff to consult with my Case Worker, Cash Aid Eligibility Worker and Employment Specialist in order to discuss or release past or current information as it pertains to the following aspects of my case:

School Records/Transcript Information
Employment Information
CalWORKs/WDC Case Management Information
Job Placement
Cash Aid Verification
Financial Aid Information
Child Care Information

This release shall remain in effect during the entire duration of my enrollment or until revoked in writing.

By checking this box, I understand by typing my name will be considered my official electronic signature.

Student Signature

Date

Main Campus

Fort Irwin Campus