Last name / Apellido
First name / Primer nombre
Middle Name / Segundo nombre
Preferred Name/ Nombre Preferido
Date of birth / Fecha de nacimiento
Student ID Number/ Número de identificación de estudiante
Imatch Number/ Número de identificación de IMatch
Address / Domicilio
City / Ciudad
State / Estado
Zip code / Codigo P.
Is your mailing address different than your address?
Mailing Address / Domicilio
Primary phone number / Numero de teléfono
Alternate phone number / Numero de celular
Email address / Correo electrónico
Gender identity / Identidad de genero
Primary language spoken at home / Primer idioma
Other languages spoken by student: / Habla otros idiomas
Race (Choose one or more)
Member of which tribe?
Are you a veteran of the United States Armed Services? / ¿Es Ud. Veterano de Los Estados Unidos?
Are you the spouse of veteran of the United States Armed Services? / ¿Es su conyugue veterano de las fuerzas armadas de los Estados Unidos?
Do you have a criminal record?/ ¿Tiene Ud. record criminal?
If Yes/ Si:
Is your current housing situation stable? / ¿Su situación de vivienda es estable?
Estimated Family Income / Ingresos aproximados de la familia
Pell Grant / Beca Federal
Oregon Promise / Promesa Oregon
Oregon Opportunity Grant / Beca de Oregon
Scholarships / Becas
Student Loans / Prestamos
Work-Study /Empleo de estudio
Are you currently / Esta actualmente (mark all that apply)
Are you currently receiving support finding a job, getting training anywhere, or enrolled in any programs such as Klamath Works, WorkSource, Oregon Employment Department or Goodwill? If so, please describe / ¿Está trabajando actualmente con Klamath Works, WorkSource, Oregon Employment Department o Goodwill?
Are you currently a student? / ¿Es usted un estudiante?
If yes, are you enrolled for:
Have you completed your High School Diploma or GED? Deben tener un Diploma de la Preparatoria o un Diploma General de Equivalencia (GED)?
Highest grade you completed / Grado de educación:
Highest grade parent/guardian 1 completed / Grado de educación:
Highest grade parent/guardian 2 completed / Grado de educación:
Attended School in another country / Estudio en mi país de origen
If Yes, where? Please enter the school name[s] & location[s] / Describa por favor nombre locación:
Employment / Empleo
Accommodations are available through Disability Services. If you have a disability that requires academic adjustments or services, please contact Disability Services as soon as possible for details on eligibility & deadlines to receive services. Some accommodations require several weeks to prepare. / Servicios de adaptación están disponibles, si usted tiene una discapacidad que requiere servicios y ajustes académicos, póngase en contacto con servicios de discapacidad tan pronto como sea posible para obtener información sobre elegibilidad para recibir los servicios. Algunas adaptaciones requieren varias semanas para poner en su lugar.
Are you currently working? / ¿Esta usted trabajando?
Name of your current employer
Current Job Title
Benefits?
Current Wage
Average hours currently worked per week?
When were you last employed? (Month and Year)
Name of your most recent employer
Most recent Job Title:
Why did you leave your last job?
Do you have a current Driver’s License?
If no, do you have a current ID?
Name of the person referring?
Location and name of the person referring?
Name of agency and person referring?
Student Signature / Firma
Date / Fecha
Parent or Guardian Signature / Firma del padre o tutor
