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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)
Are you currently a student at Palomar College?(Required)
Name(Required)
Preferred contact method(Required)

Enrollment & Academic Connection

Primary Campus / Center(Required)
Do you currently have an education plan on file?(Required)
Are you connected to any campus programs?(Required)

What Support Are You Looking For?

Check all that apply?(Required)

Urgency

Do any of these apply right now?(Required)

Tell Us What is Happening

Housing & Household

Current Housing situation(Required)

Income & Resources

Has your income or work situation changed recently?(Required)
Which resources do you currently receive or use?
Have you already asked another Palomar office/program for help with this same need?

Follow-Up

How would you prefer to meet?(Required)
Do you need accessibility or language accommodation for the meeting?(Required)

Acknowledgement & Permission

Consent(Required)