Ventura College

Intake Application

Personal Information:

Name: ___________________________ Date: ______ Semester: Fall Spring Summer Year: 20______

Student I.D.: 900 _____________________ Date of Birth: ______/_____ /___________

Address: _____________________________________ City: ___________________ Zip Code: ______________

VCCCD Email: ___________________________@my.vcccd.edu Contact Phone Number: ____________________

Educational Information:

Have you attended another College or University? Yes No Did you receive a degree? Yes No

If yes, name college/university: _________________________________________________________________

Occupational Goal: ______________________ Educational Goal: Certificate AA/AS Transfer

County Approved Degree/Program of Study: _________________________________________________

(i.e. Business Management, Child Development, etc.)
WTW/County Information:

Employment Specialist (Worker) Name: ______________________________________________________

Office Location: ________________________ Case Number: ___________________

Services Provided: (circle applicable) Books / Supplies / Fees / Mileage / Parking permit /Other ____________

Do you receive Cash Aid Assistance from the County of Ventura for yourself? Yes No

Do you receive Cash Aid Assistance from the County of Ventura for your child? Yes No

Student Family Status: 1 Parent Family 2 Parent Family

Number of Dependents (not including yourself): _______ Dependents in Child Care: ______

On Campus Child Care Hours: _________ Off Campus Child Care Hours: ___________

Financial Aid Status:

Have you applied for FAFSA? Yes No Have you applied for the BOG Waiver? Yes No

On Campus Services:

Are you receiving services from EAC? Yes No Are you in EOPS/CARE? Yes No

Employment:

Are you currently employed? Yes No Name of Employer: ______________________________

Weekly Work Hours: _____ Hourly Wage: _______ Begin Date: ___/___/____ End Date: ___/___/____
 Waiver of Confidentiality
I authorize Ventura College staff to disclose information regarding, academic progress, school attendance,
assessment results, childcare resources, financial aid and work study information and CalWORKs
compliance issues to qualified individuals from other agencies. Agencies include: Ventura County
Community College District staff, Ventura County Human Services Agency, Mental health department,
Workforce Development Division of the County of Ventura, Child Development Resources, Employer,
and other related educational providers. I release the right to use my name and photograph for all
publications, public information and all press releases relating to Ventura College and the CalWORKs
program. I affirm that all the information that I have provided on this intake form is correct.

Students Signature Date .

This waiver shall remain in effect until withdrawn by the student.

Staff Use Only

Referred to: EOPS CARE EAC FINANCIAL AID

Student is Ineligible due to the following:

WTW Discontinued, date: ________

Timed Out, date: ________

Sanctioned during current term, date of sanction: _________

Other: ____________________________________________

Comments:

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