CARE Interest Form

COOPERATIVE AGENCIES RESOURCES FOR EDUCATION (CARE)

CARE is a supplemental program that assists Eligible EOPS single parents with children under 18 years of age.

The parent or the child must be a current recipient of CalWORKs-CASH AID.

This is not a CARE application

The information you share will help us determine how best we can help you.

We will connect with you via email and/or phone call as soon as we can possibly can.

Please answer the following questions by answering yes or no as it applies:

Date/Time

:

Student ID #*

Name*

First Name

Last Name

Address*

Address Line 1

City

State

ZIP Code

Phone*

Email (provide your Panther email account)*

Are you 18 years old or older?*

Yes No

Are you currently in the EOPS Program?*

Yes No

How did you hear about the CARE Program? Select all that apply. If not found, click on other and add a short note.*

Friend Recommendation Referred from CalWORKs Program Referred from an EOPS Counselor Referred from Panther CARE Saw a flier Saw the CARE Program website Referred by an Instructor Referred from another program/services at Chaffey College

Other:

Are you or your children receiving cash aid from the county?*

Yes No

Other:

Are you a single head of household parent?*

Yes No

Are any of your children younger than 18 years of age?*

Yes No