GROVE SCHOLARS PROGRAM FALL 2012 APPLICATION COVER SHEET NAME: _____________________________________________________

GROVE SCHOLARS PROGRAM
FALL 2012 APPLICATION COVER SHEET
NAME: _____________________________________________________
The following items are in my Grove Scholars Application:
____ Fall 2012 Grove Scholars Application
____ Student Education Plan completed with a counselor showing:
1. 2 semesters of coursework planning (Fall 2012 and Spring 2013)
2. Full-time enrollment in Fall 2012
3. At least ONE course in your CTE program for Fall 2012
_____ Answers to the 5 application questions that are printed on separate
sheets of paper.
____ SparkPoint Welcome Form
____ SparkPoint Baseline Form
____ SMCCD Consent of Release
____ SparkPoint Financial Coaching Participation Sheet
Submit your completed application to the SparkPoint Center
in Building One, Room 1222.
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
Address:______________________________________________________________________ Apt #: ___________
City: ___________________________
State: _____
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
Are you a veteran?  Yes  No
Marital Status:
 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
 Event
 Friend/family  TV/news/internet
 Nonprofit agency/staff
 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?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Date: ____/____/____
BASELINE FORM
Please print carefully. This information is used to serve you more effectively, and to help us understand where
you are starting. To learn more, please see a SparkPoint staff member. All information is confidential.
A
B
Personal and Household Information
1. First Name: ____________________________________ Last Name: ____________________________________
2. How many people in the following age ranges live in your household, including yourself?
_____ Infants (0-2 years)
_____ Teenagers (13-18 years)
_____ Preschoolers (3-5 years)
_____ Adults (18 and over)
_____ School-Age Children (6-12 years)
3. What best describes your living situation?
 Renting
 Shelter or temporary housing
 Own a home  Live with family or friends
 Section 8 or subsidized housing  Currently without housing
Monthly Income Information
$ ____________
Other Household Members Earned Average Gross Income: $ ____________
Participant Earned Average Gross Income: Do you receive public benefits?  Yes  No
Monthly Public Benefits Income (Please check all that apply.):
 CalWORKS/TANF:
$ __________  School Lunch: $ __________  SSI/SSDI/Disability:
 SNAP/Food Stamps: $ __________  WIC: $ __________  Head Start:  General Assistance: $ __________  Unemployment: $ __________  Utilities/HEAP:  Subsidized Childcare: $ __________  Lifeline $ __________  All Other Benefits:
Telephone Bill Assistance
Do you have other sources of income?  Yes  No
C
Other Sources of Income:
 Child Support: $ __________
 Scholarship: $ __________
 Alimony: $ __________
 All Other: $ __________
Total Income
Savings, Assets and Credit Score Information
$ _________
$ ___________
Do you have any of the following accounts? Please check all that apply.
Total Balance
 Checking
$ ______________
 Cash on hand (mattress money)
$ ______________
 Prepaid debit card
$ ______________
 Savings
$ ______________
 Individual Development Account (IDA) $ ______________
 Retirement Account
$ ______________
 Investments
$ ______________
 Education Fund (self or your children) $ ______________
 All Other _____________________
$ ______________
Monthly Contribution
$ ___________
$ ___________
$ ___________ Client reached IDA Goal  Yes  No
$ ___________
$ ___________
$ ___________
$ ___________
Total Savings $ ______________
Do you own a car:  Yes  No
If yes, what is the value?
$ ______________
Personal Goal: What is your savings goal: $ ______________
For SparkPoint Staff Only: Client has a credit score:  Yes  No
version 12/1/2011
 Work Study (for students):
$ _________
$ _________
$ _________
$ _________
|
Self Sufficiency Standard: ______
Credit Scores: Equifax ______ TransUnion ______ Experian ______
For Sparkpoint Staff Only ETO Data Entry: Initials__________Date__________
Name: __________________________________________
D
E
Debt Information
Please check all that apply.
 Credit Card Debt
Credit Card #1 Name ______________
Credit Card #2 Name ______________
Credit Card #3 Name ______________
Credit Card #4 Name ______________
 Personal Loan (friend, relative)
 Student Loans
 Mortgage  Vehicle Loan  Medical Debt  Back Taxes  Payday Lender  Utilities Debt
 Child Support Owed  Collections Debt
 All Other Debt ______________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Total Balance $ ____________
Minimum Monthly Payment $ _________
Minimum Monthly Payment $ _________
Minimum Monthly Payment $ _________
Minimum Monthly Payment $ _________
Minimum Monthly Payment $ _________
Minimum Monthly Payment $ _________
Minimum Monthly Payment $ _________
Minimum Monthly Payment $ _________
Minimum Monthly Payment $ _________
Minimum Monthly Payment $ _________
Minimum Monthly Payment $ _________
Monthly Payment $ _________
Monthly Payment $ _________
Minimum Monthly Payment $ _________
Total Debt $_____________ Total Min Monthly Payments $ _________
Monthly Expenses
Please only fill in the fields applicable to you. If you do not have these expenses, leave blank.
1. Housing and Utilities
Rent Phone Electricity/Gas
Water/Sewer
Cable Internet Garbage/Waste Removal Maintenance and Repairs Home/Renters Insurance All Other Housing Costs
$ ___________
$ ___________
*Subtotal $___________
3. Medical/Dental Costs Prescriptions Health Insurance Out of Pocket $ ___________
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
*Subtotal$___________
2. Food Groceries Dining Out *$ ___________
$ ___________
$ ___________
$ ___________
*Subtotal $___________
4. Education
Are you or your spouse in school?  Yes  No
Tuition $ ___________
School Supplies $ ___________
*Subtotal $___________
Child Care
Children School Tuition Children School Supplies Children Clothing Children Toys/Games
Child Support Cost
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
All Children Other Costs
$ ___________
Public Transportation/Taxi
Auto Insurance Car Share or Rental
Fuel
Maintenance
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
*Subtotal $___________
*Subtotal $___________
7. Other Expenses Legal Donations Pet Costs Entertainment Personal Care Cost (clothing, hair)
Remittance Miscellaneous Costs
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
$ ___________
*Subtotal $___________
8. Taxes Paid Monthly (from pay stub)
Federal taxes
State taxes
Local taxes Social Security
5. Transportation 6. Children
*$ ___________
*$ ___________
*$ ___________
*$ ___________
Subtotal $___________
Sum of Expenses Subtotals $ ___________
Total Min Monthly Payments $ ___________
Total Expenses $ ___________
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:

SMCCCD educational records, including academic progress, educational plans

Photographs for use in newsletters, flyers and promotional material

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Academic and career assessment results
Financial Aid assistance and / or scholarship awards

Employment preparation and status

Post-education planning

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:

San Mateo County Human Service Agency

United Way – Bay Area

Jewish Vocational Service (JVS)

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. ____________________________________ ____________________________________ Signature Name __________________ __________________ ______________________________ G# Contact # Email Address Grove Scholars Program Application FALL 2012 APPLICANT’S NAME: ____________________________G#: _____________ 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 Wednesday, April 11, 2012 at 4:00pm. The Grove selection committee will review your application and will notify you via e‐mail, if selected, by Friday, April 27, 2012. You must reply via e‐mail (grovescholar@smccd.edu) by Tuesday, May 1, 2012 if you choose to accept the award. Basic Eligibility Requirements 1. Complete the Free Application for Federal Student Aid (FAFSA) for the 2012 ‐2013 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. ForInternalUse
DateAppRec’d:_______________
TimeAppRec’d:_______________
PERSONAL INFORMATION Name of Grove Scholarship applicant (Last, First, and M.I.): _____________________________________________________________ G#: __________________ Phone #: ____________________ E‐mail: _______________________________ Address: _________________________________________________________________________________ Street City State Zip code Gender: Male Female Decline to state How did you hear about the Grove Scholars Program? Instructor Counselor 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 International Students Puente 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 PATTY KWOK AT (650) 738‐7045 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 
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Accounting Accounting Computer Specialist Administrative Assistant Administration of Justice Automotive Technology Biotechnology Manufacturing Biotechnology Technician Business Information Systems 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 Respiratory Therapy Solar Energy Technology Solar Installation Surgical Technology Telecommunications & Wireless Technology