Intake Application
GSP provides counseling, resources, and other essential services to students at Chabot College who are currently or were formerly in foster care to support their journey towards academic and personal success.
Name
*
First Name
Last Name
Last 4 numbers of your Chabot student W#
I do not have a student W#
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*
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Age
*
Contact information
Mailing/Home Address
Street Address
Street Address Line 2
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Country
Phone number
*
Email
*
Zone Email
Chabot College zone email
Do you have children under the age of 18 years old?
Yes
No
Foster Care Experience
Student must be able to provide a ward of court letter. Please ask your social worker or call the Ombuds office at 1-877-846-1602.
Please check all that applies:
*
I have a letter stating that I was in foster care " Ward of the court letter".
I am currently in foster care: Dependent/AB-12/ Non-minor dependent/ Probation.
I was in Foster Care on and after the age of 13.
I was in Foster Care on and after the age of 16.
Do you (or will you) participate in AB-12 (extend foster care benefits) through your 21st birthday?
Have you participated in ILSP or BE (Beyond Emancipation)?
Please check all that applies:
I have a letter stating that I was in foster care " Ward of the court letter"
I am currently in foster care: Dependent/AB-12/ Non-minor dependent/ Probation.
I was in Foster Care on and after the age of 13.
I was in Foster Care on and after the age of 16.
Do you (or will you) participate in AB-12 (extend foster care benefits) through your 21st birthday?
you participated in ILSP or BE (Beyond Emancipation)?
County of Jurisdiction
ex. Alameda County
Social worker(s) name:
Education
High school education information
Last high school attended:
*
Did you have an IEP or 504 Plan in High School?
Yes
No
I don't know
I may have a learning disability and interested in receiving support.
Did you graduate from High School or receive a High School Equivalency Certificate (such as the GED)?
Yes
No
Graduation Year:
List any colleges you've attended and any degree/ certificates earned?
Academic & Career Goals
(College & Future)
What is your academic major?
*
ex. Business/ Nursing/ Undecided
What is your career goal?
ex. Start a Business
Do you want to transfer to a 4 year university?
Ex. Yes/ No/Undecided
Student Success & Support Services
Have you completed the following? (Check all which apply)
FAFSA 20-21 (Online Financial Aid Application)
Chafee Grant ($5,000 grant if you were in foster care after 16th birthday)
Math & English Chabot guided self-placement
Online Orientation
Met with a Chabot counselor and have a SEP (Student Education Plan)
Registered in classes
Forwarded my Chabot Zone mail
Are you participating in any of the following programs at Chabot College? (Check all which apply)
EOPS
UMOJA
PUENTE
RISE (Restorative Integrate Self-Education)
Disable Student Resource Center
Veterans Center
CalWORKs
TRiO/ MESA
Housing & Transportation & CalFresh
What is your current housing status? ( check all which applies)
*
THP
THP-PLUS
Live with foster parents
Live with family
Live on my own (Not in foster care)
I am homeless
Do you need housing resources or support?
Yes
No
Are you currently employed?
No
1-10 hours
11-20 hours
21-39 hours
40 hours
What is your form of transportation?
Car
Bus/BART
Uber/Lyft
CalFresh- is a form of food financial aid. Please answer all that applies.
Yes, I'm receiving CalFresh benefits
No, I'm not recieving CalFresh benefits
I'm interested in receiving assistance with completing a CalFresh application
Authorization
By student applicant.
I certify that the above information is true and correct. I would like to receive communication from the GSP program.
I consent to the sharing of eligibility and academic information between Chabot College and Beyond Emancipation.
I consent to the use of pictures.
Signature
Date
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Month
-
Day
Year
Date
Submit
Should be Empty: