Intake Request Form

Our staff monitors these requests during business hours only M-F 8am-5pm.

If you're facing an emergency, call 911 immediately. For non-emergency resources, dial 211 to connect with community services.

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Basic Needs Resource Directory
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At Golden West College we understand that not everyone's path to success is straightforward. Our Student Services team is here to help all students overcome challenges outside of the classroom. Our team will connect you with on-campus and community resources tailored to your needs.

If you are interested in financial assistance, our previous Basic Needs Grants program is transitioning to a new program called Fresh Success. Community resources and items requested (if available) will only be provided.

Please fill out Fresh Success application if you are interested in financial assistance. Limited funding is available!
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Who is filling out the form

Full Name

Email Address

Student Information

First Name

Last Name

Phone Number

Preferred Language

Select the best status that applies to you

Do you have children?

Assistance Currently Receiving

Do you receive any of the following assistances?

CalFresh (Food Stamp)

CalOptima

CalWORKs

Medi-Cal

Medicare Emergency

Medical General

Relief Childcare

Supplemental Security Income

None of the above

In which of the programs are you currently enrolled? (Select all that applies)

Financial Aid

EOPS (Extended Opportunity Programs and Services)

CalWORKS

The Stand: Basic Needs Center

DSPS (Disabled Students Programs and Services)

Dream Success

Golden Pride

Mesa/Raices

Puente

Academic Success Center

Campus Life (Clubs & Student Government)

Veterans Resource Center

Career Center

Transfer Center

None of the above

Housing Status

Please select your living situations:

I am living in living in a car.

I am living in a shelter.

I am couch surfing

I am at-risk of being homeless (lack a fixed, regular, and adequate nighttime residence)

None of the above

How long have you been unhoused?

Are you under the age of 24?

Yes

Areas of Assistance Needed

Select the following reason for an appointment:

I am requesting a homeless determination letter. (for students under the age of 24)

I have an eviction, 3/30/90 day notice.

I am in need of hygiene, clothing, and/or baby supplies etc.

I am requesting referrals for shelters.

I am requesting financial assistance.

I am in need of community resources.

Other

Please upload a 30-day notice, 90-day notice or eviction notice and current lease agreement.

Upload a pdf or word document

You indicated that you are interested in financial assistance. Our previous Basic Needs Grants program is transitioning to a new program called Fresh Success.

Please note: During your appointment, only community resources will be provided.

Select “Yes” if you would like to schedule an appointment now for community resources and items only.
Select “No” if you would prefer to apply for the Fresh Success program and do not need a basic needs appointment. Please fill out the Fresh Success application.

You indicated that you are interested in financial assistance. Our previous Basic Needs Grants program is transitioning to a new program called Fresh Success.

Please note: During your appointment, only community resources will be provided.

Select “Yes” if you would like to schedule an appointment now for community resources and items only.
Select “No” if you would prefer to apply for the Fresh Success program and do not need a basic needs appointment. Please fill out the Fresh Success application.

Yes

Please explain your situation as best as possible. This will help prepare the case managers to assist you with resources available.

I am in need of the following items:

Diapers

Formula

Baby Wipes

Socks

Breastmilk Bags

Men Hygiene Kit

Women Hygiene Kit

Men underwear/boxers

Women underwear

Women Bras/Bralettes

Women Sweaters

Women Pants

Women T-Shirt

Men T-Shirt

Men Sweater

Socks

Shoes

What sizes do you need in clothing/shoes/diapers or preferable feminine hygiene items? (Please note that these items are not guaranteed, as they depend on donations.)

Are you interested in applying for CalFresh (foodstamps)?

Yes

Select the resources you are interested in:

Parenting/Baby Supplies

Housing

Food

Health

Hygiene

Clothing

Other

In the last 12 months, were you ever worried you would run out of food before you had money to buy more?

Often true

Sometimes true

Never true

Don't know/Prefer not to answer

In the last 12 months, did you ever run out of food and not have money to buy more?

Often true

Sometimes true

Never true

Don't know/Prefer not to answer

Typing your name exactly as it appears below signifies you are completing this form using an electronic signature. I agree with my electronic signature shall have the same effect as my written signature.

Yes

Signature