OPPORTUNITY GRANT PROGRAM

Date Received
eJas ID
CES Initials __________
Start Date
OFFICE USE ONLY
BFET Application 2014-15
Instructions: Fill in all sections. Return completed application to the Career Center. Incomplete forms may delay selection
process. Contact the LCC Career Center 360-442-2330 with questions.
CONTACT INFORMATION
Student’s Name (Last, First, M.I.) __________________________________________________________________________
Street Address _______________________________________________________ P.O. Box _________________________
City, State, Zip ______________________________________________________ County ___________________________
Home (____) __________________ Cell (____) ___________________ Email ___________________________________
Student I.D. No. ___________________ Social Security No.* ___________________
I am a: U.S. citizen
□YES □NO
Permanent Resident
□YES □NO
Length of continuous time lived in Washington ____years ____months
Date Of Birth__________________
Washington Resident
Gender
□YES □NO
□F □M □No Answer
*You are required to provide your Social Security Number so that we may process your application. Questions concerning use of your SSN: Contact the LCC
Financial Aid Director.
EDUCATION
□GED □High School Diploma □ Certificate:
Field
□ Associate’s Degree:
□ Bachelor’s Degree or higher:
Field
I have earned a(n)
Field
Please check your current or planned major at LCC (AAS –Associate of Applied Science) (COP-Certificate of Proficiency)
(COC-Certificate of Completion) Please check only one:
□Accounting Technology (AAS)
□Adult Basic Ed/High School 21+
□Automotive Technology (AAS)
□Business Management (AAS)
□Retail Management (COP)
□Business Technology (BTEC)Administrative Services Manager
(AAS)
□Business Technology (BTEC) –
Medical Administrative Support
□Business Technology (BTEC) –
Administrative Assistant (COP)
□Business Technology (BTEC) –
Medical Reception (COP)
□Business Technology (BTEC) Billing & Coding (COP)
□Chemical Dependency Studies
(AAS)
BFET Application
□ Computer Aided Design (COP)
□ Information Technology
Systems (AAS)
□ Criminal Justice (AAS)
□ Diesel Technology (AAS)
□Early Childhood Ed. (AAS)
□Early Childhood Ed. (COP)
□ Education-Elementary with
Paraeducator Ed (AAS and COP)
□Fire Science (AAS)
□ Machine Trades (AAS)
□Machinist (COP)
□CNC (COP)
□ManufacturingAdvanced (AAS)
□ Manufacturing-Process (COP)
□ Manufacturing-Occupations
Core (COP)
□Medical Assisting (AAS)
□Medical Assisting (COP)
□Registered Nurse (AAS)
□Licensed Practical Nurse (COP)
□Health Occupations Core (COC)
□Nursing Assistant Certified
(formerly CNA) (COC)
□Welding (AAS)
□Welding (COC)
□ICP (Individualized Certificate
Program):List specific ICP here:
________________________
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I am the first person in my family to attend college
Total credits earned at LCC __________
□YES □NO
I am a
□returning student □new student to LCC
Total credits earned other than at LCC (if any): _____________
INCOME ELIGIBILITY
I have applied for Special Conditions with Financial Aid (if there has been a 30% change in income):
I am eligible for Financial Aid
□YES □NO
□YES □NO □NA
□DON’T KNOW
Please place a check mark next to all sources which you are receiving financial aid from:
□Displaced Homemakers Program □Emergency Loan
□Pell Grant / Loans
□Work Study
□Student Success Funding
□Worker Retraining Program
□State Need Grant
□WorkSource/WIA/Trade Act □Opportunity Grant
□WorkFirst/WorkFirst Fin. Aid
□Other(s) ___________________________________________________________
If No, please explain: □ Default □ Selective Service □Suspended □Other __________________________________
FAMILY INCOME
I am currently on the TANF Program:
Yes
□
No
□
□ I have completed FAFSA - 2013 tax info for 2014-15 academic year
Are you currently working? □YES □NO
Eligibility for Basic Food
What is the current monthly income of your household? $_______________
Number of people in your household? _______________
Are you eligible for, or currently receiving, basic food benefits?
View chart for eligibility
□YES □NO
□ALREADY RECEIVING BENEFITS □DON’T KNOW
Will you need child care while you are attending classes?
□YES □NO
STUDENT COMMITMENT
Please INITIAL and SIGN below
My initials and signature below indicate that if I am selected and while I am in the program, I understand and I agree:
_____
I will immediately contact a BFET Staff member if my income, program of study, or enrollment changes.
_____
I am responsible for meeting with a BFET staff member–at least monthly to verify monthly career activity.
_____
I authorize Lower Columbia College to share my quarterly course schedule with DSHS when/if requested.
Signature __________________________________________________
BFET Application
Date___________________
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Release of Information
Department of Social & Health Services (DSHS)
I, _____________________, give permission for the Washington State Department of Social and Health
[Print name]
Services and Lower Columbia 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 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 consent 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 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.
Signature ___________________________________________
Date___________________
It is the policy of Lower Columbia College to provide equal opportunity in all facets of education, hiring and continued employment
regardless of sex, race, marital status, creed, color, age, national origin, sexual orientation, the presence of any sensory, mental or
physical disability, Vietnam era or disabled veteran status, or religious preference.
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Basic Food and Employment & Training Program (BFET)
Employment Plan for:
Name (First/Last):
ACADEMIC GOALS
 Interest Assessment
Goal of Training:
 New Career
Program of Study:
 Skills upgrade in current occupation
 ESL/ABE/GED classes
CAREER GOALS
What type of career do you plan to start after your training?
How strongly do you feel about this career choice?
What types of workplaces hire individuals in this occupation?
% (100% is sure; 0% is unsure)
EMPLOYMENT BACKGROUND
Are you currently working? Yes  No
Company?
What is your position title?
Please list positions/jobs that you have held in the past:
List any skills from current or past positions that can be applied to your desired career (i.e.
customer service, typing, etc.)
POTENTIAL BARRIERS
Check any issues that would affect your ability to gain employment in your desired field.
 Transportation/Driver’s
 Lack of Education
 Family or Personal
License Issues
 Child Care
Issues
 Legal or Criminal History
 Limited English
 Technology
 Disabilities or Learning
 Financial Needs/Living
 Gaps in Employment
Challenges
Expenses
 Addiction Problems
Others not listed:
SUPPORTIVE RESOURCES
How can the BFET program best support your educational goals? Check all that apply:
□Career Counseling
□Job Search and Resume help
□Financial Aid Advising
□Help with Technology
□Mentoring/Coaching
□Personal Support
□Help with Test Anxiety
□Study Skills/Tutoring
□Other(s) ___________________