GROVE SCHOLARS PROGRAM Spring 2013 APPLICATION COVER SHEET NAME: _____________________________________________________

UNITED WAY BAY AREA
GROVE SCHOLARS PROGRAM
Spring 2013 APPLICATION COVER SHEET
NAME: _____________________________________________________
The following items are in my Grove Scholars Application:
____ Spring 2013 Grove Scholars Application
____ Student Education Plan completed with a counselor showing:
1. 2 semesters of coursework planning (Spring 2013 and Summer
2013 or Fall 2013)
2. Full-time enrollment in Spring 2013
3. At least ONE course in your CTE program for Spring 2013
_____ Answers to the 5 application questions that are printed on separate
sheets of paper.
____ SparkPoint Welcome Form
____ SMCCD Consent of Release
____ SparkPoint Financial Coaching Participation Sheet
Submit your completed application to the SparkPoint Center in Building One,
Room 1222 November 15th at 5:00 pm.
If you need any assistance with completing the Grove Scholars application packet,
please visit the SparkPoint Center in Building One, Room 1222.
NOTE: All information provided will be kept confidential with the San Mateo
Community College District.
Date: ____/____/____
WELCOME FORM
Please print carefully. This information is used to serve you more effectively, and is only used for SparkPoint
programs. To learn more, please see a SparkPoint staff member. All information is confidential.
A
Personal Information
First Name: ___________________________________ MI: _____ Last Name: ___________________________________
Date of Birth: ____/____/____ Gender:  Female  Male  Do not identify
Address:______________________________________________________________________ Apt #: ___________
City: ___________________________
State: _____
Zip Code: ________________________
Home Phone: (_____) ______ - ___________ Cell Phone: (_____) ______ - ______________
Work Phone: (_____) ______ - ___________ Email: _____________________________________________
What is the best way to contact you?  Phone  Email  Text (Carrier:_____________)
Are you an active military personnel?  Yes  No
Are you a veteran?  Yes  No
Marital Status:
 Single  Living with a partner  Married
 Widowed  Divorced/Separated
 Registered Domestic Partnership
Ethnicity:  African American  African
 Native American
 Asian
 Caucasian
 Latino  Native Hawaiian/Pacific Islander  Middle-Eastern/Arab  Multi-racial  Decline to State
 Other: __________
Primary Language Spoken At Home: ___________________
How did you hear about the SparkPoint Center?
B
 2-1-1
 Workshop
 Event
 Friend/family  TV/news/internet
 Flyer/brochure
 Nonprofit agency/staff
 Walk-in
If referred, what is the name of the person, workshop or agency? ________________________________________________
Education and Financial Information
What is your highest level of education completed? (Check ONE)
 Eighth grade or less
 Some high school  High school diploma/GED
 Some college
 Two-year degree
 Four-year degree
 Trade/vocational certification
 Graduate/Professional degree
What is your estimated yearly household income before taxes?
 $0-9,999
 $15,000 – 19,999
 $30,000 – 39,999  $50,000 – 59,999
 $10,000 – 14,999
 $20,000 – 29,999
 $40,000 – 49,999  $60,000 – 69,999
 Over $70,000
What is your estimated debt?
 $0-499
 $1,000-1,999
 $3,000-3,999
 $5,000-5,999  $500-999
 $2,000-2,999
 $4,000-4,999  $6,000-9,999
 Over $10,000
What is your current estimated savings?
C
 $0-499
 $500-999
 $1,000-1,499
 $1,500-1,999
 $2,000-2,999
 Over $3,000
Interests and Goals
Check all that apply. (Speak with a staff member to see which services are available at your center or visit www.sparkpointcenters.org)
 Affordable housing  Buying a car  Enrolling in college/school  ESL support
 Finding a job/career
 Reducing debt
 Food assistance
 Foreclosure prevention
 Free tax preparation
 Getting job training
 Starting a business
 Healthcare enrollment
 Improving credit
 Learning to budget
 Learning to save
 Money for school
 Opening a bank account
 Owning a home
 Public benefits
Please rank the top 3 areas of interest, in order of choice:
1. ______________________________
version 7/9/2012
2. ______________________________
For Sparkpoint Staff Only 3. ______________________________
ETO Data Entry: Initials__________Date__________
San Mateo County Community College District
Consent for Release of Confidential Information
___________________________________________________________________________________
Last Name
First Name
Middle Initial
___________________________________________________________________________________
G Number
Date of Birth
Other Name
I, the undersigned, hereby consent to and authorize the staff of Skyline College to release the following
information to the SparkPoint Center at Skyline College and its respective partners.
I authorize the release of confidential information, which may include one or more of the following records:
x
SMCCCD educational records, including academic progress, educational plans
x
Photographs for use in newsletters, flyers and promotional material
x
x
Academic and career assessment results
Financial Aid assistance and / or scholarship awards
x
Employment preparation and status
x
Post-education planning
x
Other (Please specify) _______________________________________
In addition, I authorize release of the same records cited above, to any of the persons or organizations listed
below for the purpose of supporting my educational goals:
x
San Mateo County Human Service Agency
x
United Way – Bay Area
x
Jewish Vocational Service (JVS)
x
Employment Development Department (EDD)
This authorization shall remain in effect until revoked in writing.
I hereby release and hold harmless all of the persons / organizations designated in this document
from any and all liability and claims of any kind, related to the release and sharing of information,
as described in the foregoing, provided by any / all of the persons and organizations indicated.
This release form has been read and reviewed with me and I understand its content.
Signed: _____________________________________
(Student or Customer / Parent / Guardian)
Consent for Release Form: Revised 030712
Date: __________________________________
SparkPoint Financial Coaching Participation Sheet
The SparkPoint Center provides the opportunity to meet regularly with a financial coach to work towards improving your financial
situation. Every SparkPoint client gets a coach who helps create a step-by-step plan to set and achieve personal financial goals –
from getting out of debt, to going to school, or finding a job. Work with a financial coach to:



Pay your Bills and Improve your Credit: Get out of debt, understand your credit, and create a household budget.
Increase your Income: Access public benefits, find a good job and start a business.
Build Your Savings and Assets: Access free and low cost banking services, matched savings account, and first-time homebuyer
programs.
____ YES, I am interested in learning more about financial coaching and would like to be contacted to set up an appointment with a
financial coach.
____ No, I am not interested in financial coaching at this time.
NOTE: All information you provide will be kept confidential with the San Mateo Community College District.
__________________________________________
Name
_____________________________
G#
____________________________________________
Signature
_______________________________
Contact #
___________________________________
Email Address
Grove Scholars Program Application
SPRING 2013
APPLICANT’S NAME: ____________________________G#: _____________
Application Checklist
A complete application packet contains the following documents:
 Grove Scholarship Application Packet (Obtained at the SparkPoint website or by emailing
[email protected]).
 Student Education Plan (SEP) that includes Spring 2013 and Summer 2013 or Fall 2013 semester.
Guidelines
Under the direction of the SparkPoint at Skyline College, Grove Scholars will receive up to $2,000 in
scholarship money and commit to participate in financial education and coaching, career counseling, and
additional services for academic success as part of the program requirement.
If you wish to be considered for the Grove Scholars Program, you must submit a complete application (see
checklist above) at the SparkPoint at Skyline College, Building 1, Room 1222 by Thursday, November 15th,
2012 at 5:00pm. The Grove selection committee will review your application and will notify you via e-mail, if
selected, by Friday, December 7, 2012. You must reply via e-mail ([email protected]) by Tuesday,
December 11, 2012 if you choose to accept the award.
Basic Eligibility Requirements
1. Complete the Free Application for Federal Student Aid (FAFSA) for the 2013 -2014 academic year, if you
have not done so. (Students not eligible to apply for federal aid may complete an alternate application available
upon request.)
2.
Complete the Grove Scholars Program Application. (Applicants must apply each semester.)
3. Enroll in a Career and Technical Education (CTE) program. (If fulfilling CTE program prerequisites, you must be
enrolled in at least one CTE course of the desired CTE program.)
4. Meet with a counselor to complete a Student Education Plan (SEP) that includes at least two semesters of
course planning (Note: Fall 2012 semester must show at least 1 CTE course and full-time enrollment). You
must make an appointment with a counselor in Building 2 to complete a SEP (no drop in’s).
5.
Maintain a cumulative GPA of 2.0 along with a 75% completion rate (Applicable to continuing students only).
6. Maintain full-time enrollment at Skyline College.
For Internal Use
Date App Rec’d:_______________
Time App Rec’d:_______________
PERSONAL INFORMATION
Name of Grove Scholarship applicant (Last, First, and M.I.):
_____________________________________________________________
G#: __________________ Phone #: ____________________ E-mail: _______________________________
Address: _________________________________________________________
Street
Gender:
City
Male
State
Female
Decline to state
How did you hear about the Grove Scholars Program?
Instructor
Counselor
Zip code
Email
Friend
Flyer
SparkPoint Center
Class Announcement (Indicate class): _________________
Other (specify): ___________________________
ACADEMIC INFORMATION
What CTE program are you pursuing? _____________________________
Start date of CTE program courses (month/year) _______________________
Date expected to complete CTE program (month/year) ________________
How many CTE units do you have left to complete? ___________ units
What classes in your chosen CTE program have you completed? _________________________________________
_____________________________________________________________________________________________
What classes in your chosen CTE program are you currently taking (include prerequisite(s) to CTE classes)?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Are you part of any of the following learning communities or programs? Check all that apply.
ASTEP
DSPS
Scholar Athlete
Hermanas/Hermanos
TRIO
First Year Experience
EOPS/CARE
SparkPoint
Honors Transfer Prog
Women in Transition
Kababayan
MESA
Puente
International Students
Other (specify): ___________________________________________
What student organization or clubs are you a part of? (i.e. Student Government, Phi Theta Kappa, Gay, Straight
Alliance, Photography Club, etc.) __________________________________________________________________
_____________________________________________________________________________________________
FINANCIAL INFORMATION
Have you completed the 2012-2013 Free Application for Federal Student Aid (FAFSA)?
Yes
No
(Students must complete the FAFSA. Students who are not eligible to apply for federal aid can complete an
alternate application. Email [email protected] for the alternate application).
List all scholarships/grants that you have received including award amount. _______________________________
_____________________________________________________________________________________________
List all other income sources with amounts for each source. ___________________________________________
_____________________________________________________________________________________________
PERSONAL STATEMENT
Please answer the following questions in essay format on separate sheets of paper. Limit EACH
response to no more than 1-typed page per question (double-spaced, 1” margins, 12 point Times New
Roman font). Please make sure to type the question before each response.
IF YOU NEED ASSISTANCE TO COMPLETE THIS APPLICATION, PLEASE CONTACT
Andrea D. Anyanwu AT (650) 738-4239 OR VIA E-MAIL AT [email protected]
1.
Statement of Need: Reflect on your current financial need and explain how the Grove Scholarship will
benefit your current situation. (Provide a thorough and detailed explanation.)
2.
Academic Commitment: Describe your commitment towards your academic goal and explain the steps
you are going to take in order to ensure a timely and successful program completion. (Please provide
specific and detailed strategies to ensure your success.)
3.
Career Goal: What do you hope to be doing in your career in five years? What steps will you take to get
there? (Give specific step-by-step examples on how you’re going to achieve career success).
4.
Job Motivation: What is your main motivation for pursuing this particular CTE program and what have
you done or what will you do to prepare to enter the job market? (Please provide detailed and specific
examples, [i.e. job-related work experience, internships, volunteer, job shadowing, job hunting, etc.])
5.
Scholarship Intent: If awarded, how will you use the funds? (Please, provide a detailed breakdown of how
you plan to spend the funds, [e.g. $200-books, $100 transportations, etc.])
APPLICANT’S CERTIFICATION
1.
I affirm that the information provided within is true, complete, and accurate, and that this award may be
revoked without appeal if the information is found by the committee to be otherwise.
2.
I permit the Grove Scholarship committee to release/forward any or all parts of my application to
agencies that they deem might have an interest in reviewing it for additional benefit.
____________________________
_________________________________
_____________
Name of applicant
Signature of applicant
Date signed
List of Approved CTE Programs
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Accounting
Accounting Computer Specialist
Administrative Assistant
Administration of Justice
Automotive Technology
Biotechnology Manufacturing
Biotechnology Technician
Business Management
Central Supply Technician/Sterile
Processing
Computer Information Specialist
Cosmetology
Early Childhood Education (ECE)
Early Childhood Special Education
Emergency Medical Technician (EMT)
Esthetician
Import and Export
Legal Administrative Assistant
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Logistics – Custom Broker
Logistics – Ocean Freight Forwarding
Logistics – Air Freight Forwarding
Manicuring
Massage Therapy
Medical Transcriptionist
Medical Billing and Coding
Medical Office Assistant
Multimedia Technology
Network Engineering
Office Assistant
Office Information Systems
Paralegal Assistant
Pharmacy Technician
Respiratory Therapy
Solar Energy Technology
Solar Installation
Surgical Technology
Telecommunications & Wireless
Technology