Special Programs & Services Application

Disclaimer: EOPS/CARE and CalWORKs are accepting Spring 2024 applications from November 20, 2023 - January 26, 2024. There is no deadline for NextUp applications.

Term

School Year

Personal Information

Student B Number

First

Middle

Last

Suffix

Preferred First Name

Date of Birth

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

Personal E-Mail

All correspondence through Special Programs & Services will only be sent through your student e-mail (my.barstow.edu)

Ethnic Background

African American

Caucasian

American Indian

Asian/Pacific Islander

Filipino

Native of Alaskan

Hispanic

Other

What language do you primarily speak?

Educational Background

What is your highest level of education?

Cumulative high school grade point average

Have you attended any Community College or University before?

If yes, when and where?

What is your educational objective/goal?

Major

Family Information

Marital Status

Family Size (including yourself)

Number of Children

Are you a current or former Foster Youth?

Were you in foster care on or after your 13th birthday?

Were you in the NEXTUP program at another college?

Are you experiencing homelessness?

Do either of your parents have a college degree?

Are your parents native English speakers?

Do you currently receive CalFresh/Food Stamp benefits?

If no, are you interested in applying?

Are you receiving CalWORKs/Cash Aid?

If yes, are you receiving CalWORKs/Cash Aid for:

If yes, how long have you received CalWORKs/Cash Aid?

County Release of Information

County Case Number

I understand that I am authorizing the Barstow Community College CalWORKs and CARE program staff to consult with my County Case Worker, Cash Aid Eligibility Worker, and Employment Specialist 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

I understand that I must complete a County Release of Information Form every semester so that SPS Staff can request my County Verification of Benefits each semester to continue receiving CalWORKs or CARE benefits.

Military Affiliation

Active Duty

Veteran

Branch

Discharge Date

Military Dependent

Emergency Contact

Name

Phone

Signature & Release

Photo Release

Occasionally the Special Programs and Services department may obtain photos of students. If you elect to release your photo you will grant permission to Barstow Community College District to use your photo for promotional use including but not limited to fliers, newsletters and brochures which may be published on physical documents or virtual/electronic content. If you do agree you waive any rights to inspect, edit or approve the final publication with your photograph. Please see staff for any questions regarding the photo release.

I authorize the Special Programs and Services Department to use my photograph for any publications

I DO NOT authorize Special Programs and Services Department to use my photograph for any publication

All applicants must read this statement and sign below:

I hereby affirm, under penalty of perjury, that all of the information provided on this form is true and complete to the best of my knowledge. I agree to provide proof/documentation of these statements if requested by a college official. I realize that any false statement or failure to provide follow up information may be cause for the denial or termination of Special Programs services. I understand that it may take up to 7 business days for my application to be processed. I authorize the sharing of information regarding this application between Barstow Community College, the college district, and the Chancellor’s Office of the California Community Colleges.

Signature Waiver

By checking this box I understand that typing my name will be considered my official electronic signature

Student Signature

Date

Mutual Responsibility Contract

Select the program(s) you plan to participate in:

EOPS/CARE/NEXTUP

CalWORKs

VETS

YESS

EOPS/CARE/NEXTUP PROGRAM SERVICES

As an EOPS/CARE/NEXTUP student, you may be eligible for the following services. All program services may not be duplicated and
are based on program and funding availability.

Priority Enrollment and Registration Assistance
Academic/Personal Advising and Counseling
Textbook Assistance
Transportation Assistance
School Supplies
Tutorial Services Assistance
Financial Aid Application Assistance
Cultural/Education Enrichment Activities
Transitional Support Services
Campus and Community Referrals
Childcare Stipends
Weekly Grocery Cards (CARE/NEXTUP Only)

EOPS/CARE/NEXTUP STUDENT REQUIREMENTS

I must enroll in and complete twelve (12) units with a 2.0 semester GPA in Spring/Fall unless I have a waiver from the director or the ACCESS program (Summer is an optional semester for continuing students)

I must complete three (3) required contacts every semester as indicated in the SPS Deadline Dates.

One (1) Program Contact: Meet with assigned EOPS/CARE/NEXTUP staff one (1) time per semester.

Two (2) Counseling Contacts: Meet with assigned SPS counselors two (2) times each semester. General counseling and
drop-in counseling do not satisfy a counseling contact.

I must attend a mandatory orientation once per academic year to be updated on program requirements.

I must follow my SPS educational plan and enroll in courses during priority registration dates.

I must choose a major within my 1st year of acceptance into the program(s). Changing my major towards the end of my academics or double majoring is not permitted and can affect my program eligibility.

I am eligible to receive EOPS services for up to 70-degree applicable units (completed at any college/university). Upon reaching the 70-unit limit, EOPS services will no longer be provided (exceptions will be made for students in high-unit majors with the director's approval).

I understand that appointment reminder alerts/phone calls are a courtesy and are not guaranteed. I must contact the SPS office if I cannot make any of my scheduled appointments. If I need to reschedule a contact, available days/times may be limited.

I must notify program staff of any changes to my class schedule and units. If I change my address or phone number, I must update this information with Admissions or Online via my single sign-on portal.

I understand that all EOPS/CARE/NEXTUP support services that I receive will be reported to Financial Aid.

I must re-certify for CARE every semester by completing a Release of Information to allow staff to request County Verification of cash aid.

I understand the EOPS/CARE/NEXTUP programs are voluntary and if I choose to no longer participate in the program(s), it is my responsibility to submit the Program Withdrawal form to avoid program dismissal.

(OPTIONAL): As an EOPS Student, I can attend three (3) workshops; as a CARE Student, I can attend five (5) workshops; as a NEXTUP student, I can attend six (6) workshops, per semester to receive additional benefit cards. I must submit a workshop form with the moderator's signature and include a paragraph summary of what I learned if I choose to attend workshops.

I understand that there is a NO TOLERANCE policy in reference to benefit cards. Any failure to follow the guidelines can result in benefit cards being revoked for the remainder of the semester. The following guidelines must be followed in order to receive this service:

1) Benefit cards are ONLY for the benefit of the SPS student that it is issued to.

2) Issues with cards must be reported to the SPS office during regular business hours and within the same semester it was issued.
3) If a card is lost, stolen, or misplaced, SPS will not replace it.

4) Benefit cards do not roll over from semester to semester. I must pick up or request my cards before the end of each semester.

I understand that all program services are based on program funding and can be modified based on the needs of the program at any time.

EOPS/CARE/NEXTUP PROBATION/DISMISSAL

I understand that failure to complete one (1) contact (counseling contact or program contact) will result in automatic program dismissal at the end of the semester.

I understand that failure to complete 12 units with a 2.0 semester GPA will result in program probation.

Students on probation will only be allowed to be on probation for two (2) consecutive semesters. Students that do not
complete the unit and GPA requirement by the end of the second semester will be dismissed and will need to "sit out"
the following semester before reapplying.
Students on probation will receive fewer benefit cards.

By signing below, I verify that I understand and agree to fulfill all program requirements. I understand that failure to do so may result in probation or program dismissal, or a hold being placed on my account.

Signature Waiver

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

Student Signature

Date

EOPS/CARE Staff Signature/Date

CalWORKs PROGRAM SERVICES

As a CalWORKs student, you may be eligible for the following services. All program services may not be duplicated and
are based on program and funding availability.

Priority Enrollment and Registration Assistance
Academic/Personal Advising and Counseling
Textbook Assistance
Transportation Assistance
School Supplies
Tutorial Services Assistance
Financial Aid Application Assistance
Cultural/Education Enrichment Activities
Campus and Community Referrals
Career Assessments and Readiness Training
On/Off Campus Job Opportunities

CalWORKs STUDENT REQUIREMENTS

I must enroll in and complete six (6) units in Spring/Fall (Summer is an optional semester for continuing students)

I must complete three (3) required contacts every semester as indicated in the SPS Deadline Dates.

One (1) Program Contact: Meet with assigned CalWORKs staff one (1) time per semester.
Two (2) Counseling Contacts: Meet with assigned CalWORKs counselors two (2) times each semester. General counseling and drop-in counseling do not satisfy a counseling contact.

As a CalWORKs Student, I must attend one (1) career focused or parenting focused workshop. I must submit a workshop form with the moderator's signature and include a paragraph summary of what I learned if I choose to attend workshops.

I understand that I am eligible to receive CalWORKs services until I receive my degree.

I understand that appointment reminder alerts/phone calls are a courtesy and are not guaranteed. I must contact the CalWORKs office if I cannot make any of my scheduled appointments. If I need to reschedule a contact, available days/times may be limited.

I understand that all CalWORKs support services that I receive will be reported to Financial Aid.

I must re-certify for CalWORKs every semester by providing a recent Verification of Benefits.

I must attend a mandatory orientation once per academic year to be updated on program requirements.

By signing below, I verify that I understand and agree to fulfill all CalWORKs Program Requirements. I understand that failure to do so may result in preventing me receiving certain benefits.

Signature Waiver

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

Student Signature

Date

Staff Signature

Disclaimer: EOPS/CARE and CalWORKs are accepting Spring 2024 applications from November 20, 2023 - January 26, 2024. There is no deadline for NextUp applications.

Personal Information

All correspondence through Special Programs & Services will only be sent through your student e-mail (my.barstow.edu)

Educational Background

Family Information

County Release of Information

Military Affiliation

Signature & Release

Mutual Responsibility Contract

Main Campus

Fort Irwin Campus

Special Programs & Services Application

Disclaimer: EOPS/CARE and CalWORKs are accepting Spring 2024 applications from November 20, 2023 - January 26, 2024. There is no deadline for NextUp applications.

Personal Information

*All correspondence through Special Programs & Services will only be sent through your student e-mail (my.barstow.edu)*

Educational Background

Family Information

County Release of Information

Military Affiliation

Signature & Release

Mutual Responsibility Contract

Main Campus

Fort Irwin Campus

All correspondence through Special Programs & Services will only be sent through your student e-mail (my.barstow.edu)