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FormTitle

Guardian Information Questionnaire

Personal Information:

Full Legal Name*

First Name

Last Name

SRJC Student ID Number (SID)

Numbers only. NO DASHES

Birth Date*

Email*

Semester Requested For:

Semester*

Year

Please answer the following:

Have you (the student) lived in California the past two years or more?

Yes No

If NO, when did your present stay in California begin?

Are you now, or have you ever been, a dependent of the State or ward of the court through California’s child foster youth system?

Yes No

Are you currently a dependent of the State or ward of the court or have aged out?

Yes No

If YES, please attach a document showing proof of your status as a dependent of the State or ward of the court.*

No File Chosen

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If NO, what is the last date you were considered to be a dependent of the State or a ward of the court?

Mother’s Name (If you do not know, please write ‘unknown’.)

First Name

Last Name

Mother's Permanent Address

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Has your mother lived in California continuously for the last two years?

Yes No

If NO, what day did her present stay in California begin?

Fathers Name (If you do not know, please write ‘unknown’.)

First Name

Last Name

Father's Permanent Address

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Has your father lived in California continuously for the last two years?

Yes No

If NO, what day did his present stay in California begin?

Where do you live?*

Both Parents Mother Father Somewhere Else

If you do not live with either parent, are you under continuous and direct care and control of a court appointed legal guardian?*

Yes No

Name of court appointed legal guardian

First Name

Last Name

Address of court appointed legal guardian

Address Line 1

Address Line 2

City

State

ZIP Code

Country

How long have you been continuously under this person’s direct care and control?

Are you an active member or the dependent of an active member of the military stationed in California?*

Yes No

If Yes: What is the active member’s anticipated end time served?

What is the active member’s State of legal residence on military records?

Student Signature

Affidavit:

I declare under penalty of perjury that the statements and information submitted in this Guardian Information Questionnaire are true and correct. I understand that all materials and information submitted by me for purposes of admission become the property of Santa Rosa Junior College. I also understand that falsification, or withholding pertinent data or failure to report changes in residency may result in District action.

Signature*

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