Intake Form

Please correct the field(s) marked in red below:

First Name
 *
Last Name
 *
Phone Number
 *
Birth Date *
Mailing address/or Forwarding Address:
 *
Mailing address/or Forwarding Address:
What is your email address?
What is your major? 
Do you have any below?
 *
Do you have any below?
Have you taken any entrance tests? (Usually during high school)
 *
Have you taken any entrance tests? (Usually during high school)
Have you previously attended any other colleges?
 *
Have you previously attended any other colleges?
Have you completed any transferrable units?
 *
Have you completed any transferrable units?
Have you completed any of the core college courses listed below?
 *
Have you completed any of the core college courses listed below?
If yes, mark the completed courses.
If yes, mark the completed courses.
Have you defaulted on student loans?
 *
Have you defaulted on student loans?
Have you completed the financial aid (FAFSA) application?
Have you completed the financial aid (FAFSA) application?
Have you completed the California Dream Act application?
Have you completed the California Dream Act application?
Which semesters do you wish to attend Glendale Community College?
 *
Which semesters do you wish to attend Glendale Community College?
Do you have a valid ID?
Do you have a valid ID?
Do you have a valid Drivers license?
Do you have a valid Drivers license?
Do you have a vehicle?
Do you have a vehicle?
Do you need a transportation voucher?
Do you need a transportation voucher?
What is your Housing situation?
Do you receive Cal Fresh (Food stamps)?
Do you receive Cal Fresh (Food stamps)?
If No, Do you need help applying for Cal Fresh?
If No, Do you need help applying for Cal Fresh?
Are you currently in need of clothing for everyday use?
Are you currently in need of clothing for everyday use?
Do you think you need access to mental health services?
Do you think you need access to mental health services?
Do you have Medi-Cal or Medicare?
Do you have Medi-Cal or Medicare?
How would you rate your health?
How would you rate your health?
Do you need medical assistance for any health issues? Please explain:
Which of these apply to you?
Which of these apply to you?
If you are currently incarcerated, what is your expected release date and county of parole?
 *
Do you need any of the following?
Do you need any of the following?
Do you need to register with law enforcement authorities or any registry?
Do you need to register with law enforcement authorities or any registry?

If you require any specific resources or forms of support, please list them below. Also include any other questions or concerns.

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