WES Funding Application Form - Big Bend Community College

First Name *

Middle Initial *

Last Name *

Preferred Name

EMPL Number (CTCLink)

Email Address

Phone *

Are you receiving any of the following?

Basic Food (Food Stamps)TANF (Cash assistance from DSHS)

2. Has DSHS identified you as an Able Bodied Adult Without Dependents (ABAWD)? *YesNo

3. Are you pursuing a degree in Early Childhood Education and working at an Early Achievers site? *YesNo

Select all applicable

Family Home Childcare owner or employeeChildcare Center owner or employeeECEAP employeeHead Start Employee

Place of employment

How long have you been working there?

4. Do any of the the following options apply to you? Please select one: *

I’m Receiving Unemployment Benefits (UI)I Have exhausted my unemployment insurance within the last 48 monthsI have been discharged from the U.S. armed services in the last 48 monthsI am a displaced homemaker (loss of primary income due to household death, separation, divorce) *within the last 48 months.I was formerly self-employed (business closure or downturn due to economy) *within the last 48 months.I am underemployed (working in a temporary job in which I am overqualified) *within the last 48 months.None of these apply to me.

If you answered yes to question #4 Print out an UNEMPLOYMENT INSURANCE (UI) DATA MALL FORM, This is available at https://secure.esd.wa.gov

5. Do you have a high school diploma or GED? *YesNo

6. Have you previously completed a college degree or certificate? *YesNo

7. Please list the program you will complete at BBCC *

8. Please indicate if you will earn a certificate or degree: *

CertificateDegree

Release of Information for Workforce Education Services Incomplete applications will not be processed. Big Bend Community College adheres to FERPA regulations regarding the privacy and confidentiality of student information. Workforce Education Services works closely with other agencies we may need to share education and financial aid information with these agencies. Your signature authorizes Big Bend Community College to release and exchange information—for the purpose of determining eligibility for Workforce Education Services—with the following agencies: Department of Social and Health Services, Working Connections Child Care, Employment Security/WorkSource, SkillSource, Department of Vocational Rehabilitation, Opportunities Industrialization Center, and other colleges. I certify that the information I have provided to Big Bend Community College, and the Workforce Education Services department, are true to the best of my knowledge. I am aware that I may have to provide documentation of support or agency verification, and this information will be used to determining eligibility for services. I understand that by not signing, I am waiving my participation in Workforce Education Services. I give permission for the Washington State Department of Social and Health Services and Big Bend Community College to use and share confidential information about me (except as limited below) as necessary for Employment and Training (E&T) activities as required by the Basic Food E&T (BFET) program. This consent is valid for a maximum of three years from the date signed, unless I withdraw or change my consent in writing. This DOES NOT permit sharing of sensitive information about my mental health, chemical dependency, HIV/AIDS, and STD test results, diagnosis, or treatment. I understand that I must fill out a separately approved consent form if I am under 18 years of age, I want to further limit the information shared about me, someone else is representing me in this matter, or I want to allow sharing of sensitive information about my mental health, chemical dependency, HIV/AIDS and STD test results, diagnosis or treatment. I attest that all information provided on this application is true. I authorize Workforce Education Services staff to verify my eligibility by reviewing my FAFSA or WASFA application, current financial aid awards, educational intent, current course schedule, transcripts, and eligibility for TANF and food benefits through DSHS.

Type your full name (release of information): *