Civicorps Corpsmember Academy Application Form With Cover Letter (Page 4 of 8) in pdf

CIVICORPS CORPSMEMBER ACADEMY

STATE REQUIRED INFORMATION

101 Myrtle Street

Oakland, CA 94607

(510) 992-7800

DIRECTIONS:

The California Education Code requires each school to collect information about its students. Each school is required to submit this

information to the State. The required information includes parent education, home language, race / ethnicity, and family income. Thank

you for your help in filling out the following four surveys.

PARENT/GUARDIAN EDUCATION LEVEL (give the response that describes the highest education level of either parent):

 Not a high school graduate

 Some college

 Graduate school / post graduate training

 High school graduate

 College graduate

 Declined to state or unknown

HOME LANGUAGE SURVEY:

What language did this applicant learn when he/she first began to talk?

What language does this applicant most frequently use at home?

What language is most often spoken by the adults at home?

Is this student fluent in the English language (speaking, reading, and writing)?

Yes

Not Sure

Has student ever taken the CA English Learner Development Test (CELDT)?

Yes

Not Sure

RACE / ETHNICITY SURVEY

Check the group with which the student most closely identifies:

Check the group with which the student also identifies (if applicable):



American Indian or Alaskan Native



Asian/Asian American



Pacific Islander

If Asian or Pacific Islander is marked, then check all

that apply:

 Chinese

 Japanese

 Korean

 Chinese

 Japanese

 Korean

 Asian Indian  Hawaiian

 Guamanian

 Asian Indian  Hawaiian

 Guamanian

 Laotian

 Cambodian

 Vietnamese

 Laotian

 Cambodian

 Vietnamese

 Samoan

 Other Asian

 Samoan

 Other Asian



Filipino/Filipino American



Hispanic/Latino



African/African American



White (not of Hispanic origin)



Other

FAMILY INCOME SURVEY:

How many people live in your household?

1A. Does applicant have child? If so, how many? ______________

Does anyone in your household receive food stamps or CalWorks or FDPIR, etc.? Yes

Approximate ANNUAL family income (please check one below):

 $0 - $10,830

 $18,311 - $22,050

 $29,531 - $33,270

 $10,831 - $14,570

 $22,051 - $25,790

 $33,271 - $37,010

 $14,571 - $18,310

 $25,791 - $29,530

 $37,011 +

Civicorps Corpsmember Academy Application Form With Cover Letter Page 4

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