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Basic Needs Intake Form

Before you begin:
Use this form to connect with Palomar College Basic Needs for help with food, housing, transportation, financial hardship, hygiene, utilities, technology, childcare, and other essential needs. Submitting this form does not guarantee financial assistance. A Basic Needs team member will review your request and follow up with you.

Immediate Emergencies:
This form is not monitored as an emergency-response system. If you or someone else is in immediate danger, call 911 or contact the appropriate emergency-response resource.

Basic Needs Intake & Resource Connection Form

About You

Are you currently a student at Palomar College?(Required)
Name(Required)
Preferred contact method(Required)
Primary Campus / Center(Required)
Do you currently have an education plan on file?(Required)

What Support Are You Looking For?

Check all that apply?(Required)
Do any of these apply right now?(Required)

Tell Us What is Happening

Privacy note: This question is optional. Please share only what you are comfortable providing and avoid including sensitive personal, medical, or financial details.
Is this affecting your ability in the following:

Housing & Household

Current Housing situation(Required)
Privacy note: Please keep your response general and avoid including identifying or sensitive personal details.

Follow-Up

How would you prefer to meet?(Required)
Would you prefer to receive information or assistance in a language other than English?(Required)
Privacy note: Please enter only the language you prefer. Do not include additional personal information.

Acknowledgement & Permission

Consent(Required)