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EOPS Application Form


EOPS Eligibility Application Form
First Name
Last Name
Birth Date
Butte College Student I.D.#
  Previous name used on academic records (if applicable):
 
Mailing Address
City
Zip
County
Primary Telephone #
Message Telephone #
Email Address
Major
Educational Goal (Please Check)
AA/ AS Degree
Certificate
Transfer
How did you find out about EOPS?
Have you been a Butte College EOPS participant before?
Yes No
Are you participating in Disabled Student Program & Services?
Yes No
GENERAL CRITERIA:
Are you a California resident?
Yes No
Number of Butte College units you are presently enrolled in
Have you completed more than 70 college units?
Yes No
Have you earned an Bachelor or higher degree?
Yes No
Have you attended any other college?
Yes No
List college(s) attended if you answered "Yes" to the above question.

(Official transcripts from other college(s) must be on file with Butte College Admissions & Records)
EDUCATIONAL CRITERIA:
Have you taken a college basic skills assessment test? If yes, where and when?
Yes No
Where:
When:
Did you graduate from high school, complete a GED or pass the high school proficiency test?
Yes No
Was your high school GPA 2.49 or below?
Yes No
Are you currently enrolled, or have you ever been enrolled, in basic skills classes (classes which do not count toward a degree)?
Yes No
Have either of your biological or adoptive parents received an Bachelor Degree?
Yes No
Are your parents native English speakers?
Yes No
My cultural background is:
ECONOMIC CRITERIA:
Have you applied for a Board of Governor's Grant ? (fee waiver)
Yes No
Have you applied for financial aid?
Yes No
C.A.R.E.
Are you a single head of household receiving cash aid from CalWORKS/TANF?
Yes No
If you selected "Yes". Scroll down to C.A.R.E. Application. Complete the information and then submit this form.
If you selected "No". Please finish this application by typing in your name and date in the following fields and clicking on the "Submit EOPS Intake Form.
The information provided is true and correct to the best of my knowledge. I understand that if I provide false information that I may be denied services and/or aid from Extended Opportunity Program and Services (EOPS) and/or Cooperative Agencies Resources for Education (CARE).
Student Signature Please type in your name. Your handwritten signature will be required later if you are found eligible for the program.
Date
Remember, if you selected "Yes" to the above question. "Are you a single head of household receiving cash aid from CalWORKS/TANF?" Be sure to scroll down to C.A.R.E. Application. Complete the information and then submit this form. If not, then please submit the EOPS Intake Form by clicking on the button at bottom of page.
 
C.A.R.E. Application
You may also be eligible for Cooperative Agencies Resources for Education (C.A.R.E.) IF you meet the following criteria:

You are currently receiving assistance from CalWORKS/TANF.
You have at least one child under fourteen years old.
You are at least 18 years old
You are a single head of household (as determined by the County Welfare Office)

The C.A.R.E. Program assists EOPS-eligible students with educational and child care expenses. Please complete the following and return to the EOPS Office to see if you are eligible for the C.A.R.E. Program.

You must answer ALL the following questions or your C.A.R.E. eligibility cannot be determined.
Marital status
Married
Years Married
Spouse incarcerated Yes No
Single (never married)
Divorced
Separated
Widowed
Unknown
Are you receiving cash aid from the County
(CalWORKS/TANF)?
Yes No
Are your children receiving cash aid from the County
(CalWORKS/TANF)?
Yes No
Beginning date on aid:
Name and ages of dependent children (under fourteen years of age):
Child #1
Age
Child #2
Age
Child #3
Age
Child #4
Age
Are you 18 years or older?
Yes No
Are you receiving services through ANY agency or organization?
Yes No
If YES, what agency?
What services are you receiving?
Childcare funding Yes No
Books Yes No
Transportation Yes No
Supplies Yes No
Tuition Yes No
Other
The information provided is true and correct to the best of my knowledge. I understand that if I provide false information that I may be denied services and/or aid from Extended Opportunity Program and Services (EOPS) and/or Cooperative Agencies Resources for Education (CARE).
Student Signature Please type in your name. Your handwritten signature will be required later when you are accepted to the program.
Date
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FOR QUESTIONS REGARDING THIS INTAKE FORM Call the EOPS Office at: 895-2555

Butte College | 3536 Butte Campus Drive, Oroville CA 95965 | General Information 530.895.2511

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