Palm Tran Bus Pass Application & Intake
Palm Beach State College
Student Name:
*
First Name
Last Name
Student ID Numer:
Date:
*
-
Month
-
Day
Year
Date
Date of Birth:
*
-
Month
-
Day
Year
Date
Age
*
Phone Number
*
Please enter a valid phone number.
Is it safe to contact you at this phone number?
*
Please Select
Yes
No
Palm Beach State Email Address:
*
example@my.palmbeachstate.edu
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name:
*
First Name
Last Name
Relationship:
*
Phone Number:
*
Please enter a valid phone number.
Marital Status
*
Single
Married
Divorced
Widowed
Separated
Domestic Partner
Other
Children
*
Yes
No
If yes, please list their ages and any relevant information
Living Situation
*
Alone
With Family
With Friends
Other
Current Employment Status
*
Employed Full-Time
Employed Part-Time
Unemployed
Student
Retired
Other
Occupation
*
Employer
*
Source of Income
*
Employment
Social Security
Disability
Unemployment
Other
Monthly Income
*
Monthly Expenses
*
Please describe the main issues or problems you are experiencing:
*
How long have you been experiencing these issues?:
*
Have you sought help for these issues before?
*
Yes
No
If yes, please provide details:
Have you ever received counseling or case management services from Palm Beach State College Student Counseling Center in the past?
*
Yes
No
If yes, please describe whom you worked with, what services were provided, and what semester?
What are your goals for seeking case management services?
*
Are you interested in a support group? If so, which?
Around the Table - Making the Pantry Work for you
Basic Needs - Community Resources
Beyond Borders
Creative Expressions
FUNctional mental health
Mastering Your Emotions
NAMI
Return/Relearn - Returning to School
Shifting Sands - Sand Tray Therapy
Stress Free Living
Turning Pages Together
Tranquil Minds - Meditation Group
Talk it Out Tuesday
Other
Please provide a brief statement explaining why you are requesting a bus pass and how this will help you remain in school.
*
The times and dates you select are not guaranteed.
I am aware to receive my bus pass, I must be currently enrolled in classes.
*
Yes
I am aware that if awarded, this bus pass is only provided to be one time. This bus is only valid for one month from the day it is activated.
*
Yes
Please state the best times and days that you would prefer your appointment:
*
The times and dates you select are not guaranteed.
What campus do you prefer?
*
Please Select
Lake Worth
Boca Raton
Palm Beach Gardens
Loxahatchee
Belle Glade
Is there anything else you would like us to know?
*Your signature below indicates that the information you have provided above is truthful.
Date
*
-
Month
-
Day
Year
Date
Print Student Name
*
Student Signature
*
Submit
Should be Empty: