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: ___________________________________ Gender: Female Male Date of Birth: ____/____/____ Address: ______________________________________________________________________ City: ___________________________ State: _____ Apt #: ___________ Zip Code: ________________________ Home Phone: (_____) ______ - ___________ Cell Phone: (_____) ______ - ______________ Work Phone: (_____) ______ - ___________ Email: _____________________________________________ What is the best way to contact you? Phone Email Are you an active military personnel? Yes No Marital Status: Are you a veteran? Yes No Single Living with a partner Married Widowed Divorced/Separated Registered Domestic Partnership Ethnicity: African American African Asian Caucasian Native American Middle-Eastern/Arab Multi-racial Latino Native Hawaiian/Pacific Islander Decline to State Other: __________________ Primary Language Spoken At Home: ___________________ Please list the people in your household/family (include anyone that you support or share expenses with): Name Date of Birth Relationship School Active Military Veteran ____/____/____ Yes/ No Yes/ No ____/____/____ Yes/ No Yes/ No ____/____/____ Yes/ No Yes/ No ____/____/____ Yes/ No Yes/ No ____/____/____ Yes/ No Yes/ No Is anyone in your household pregnant? Yes No If yes, when is the due date? ____/____/____ How did you hear about the SparkPoint Center? B 2-1-1 Workshop Flyer/brochure Nonprofit agency/staff Event Friend/family TV/news/internet Walk-in If referred, what is the name of the person, workshop or agency? ______________________________________________________________________________________ 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. ______________________________ 2. ______________________________ 3. ______________________________ What do you want to accomplish in the next year? ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ version 12/1/2011 For Sparkpoint Staff Only ETO Data Entry: Initials__________Date__________ Name: __________________________________________ C Employment and Education Information Are you currently unemployed? Yes No If yes, did you lose your job in the last 18 months? Are you available and able to work? Yes No Yes No 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 Are you currently attending school? Yes No School Attending: _______________________________________________ What degree or certificate are you pursuing? AA/AS 2 year program Transfer GED Vocational BA/BS 4 Year Program Graduate Degree Are you an English as a Second Language (ESL) learner? D E Yes No Health Insurance Information Do you and the following members of your household have health coverage, including private, employer-provided, and/or public (MediCal, Healthly Families, or Healthy Kids & Young Adults)? You: Yes No Your Spouse/Partner: Yes No N/A Your Children: Yes No N/A Financial Information Are you currently a victim of identity theft? Yes No During the last 12 months, have you: (check all that apply) Taken a loan Been behind on your monthly bills Used a credit card to pay your regular bills Had help from family and friends Used student financial aid for non-educational purposes Paid to cash a check None of the above Paid for payday advance Did you file a tax return in the United States last year? If yes, did you spend money to file your taxes last year? If married, did you file your taxes jointly? Yes No Don’t know Yes No Yes No Have you pulled your credit score in the last 60 days? Yes No 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? $0-499 $500-999 $1,000-1,499 $1,500-1,999 $2,000-2,999 Over $3,000 Do you have any questions or concerns about savings, credit, debt or taxes? Is there anything else you would like to tell us? ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 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 grovescholar@smccd.edu).  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 (grovescholar@smccd.edu) 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 grovescholar@smccd.edu 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 GROVESCHOLAR@SMCCD.EDU 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                  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                    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