Guardian Scholars Applicationssep/documents/Renaissance Scholars... · Web viewola r s 3801 W est T e mple A ve. P o mona, C A 91 7 68 Please submit your application and all supporting

RREENNAAIISSSSANANCCEESSCCHHOLOLAARRSS

APPLICATION: FALL 2016

EMPOWERING FORMER FOSTER YOUTH THROUGH HIGHER EDUCATION

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Cal Poly Pomona | Renaissance Scholars

EMPOWERING FORMER FOSTER YOUTH THROUGH HIGHER EDUCATION

RENAISSANCE SCHOLARS (RS)Is a comprehensive support service program that enables former foster youth to attend one of thenation’s finest universities and successfully complete a bachelor’s degree. This innovative program draws on Cal Poly Pomona’s Educational Opportunity Program (EOP) and the Casey Family Program’s It’s My Life framework for transitioning foster youth.

OUR MISSIONWe are dedicated to making a positive difference in the lives of non-traditional and undecided students through a broad range of high quality programs and services that promote access and equity, transition, and educational opportunities in support of student learning and success; thus empowering students to become educated and engaged citizens who go on to lead productive and meaningful lives.

O OUR VALUES:We strive for excellence in everything we do. We emphasize learning, demonstrate resiliency, encourage and model wellness, act with integrity, exemplify personal and social responsibility, and cherish relationships with others.

TPROGRAM BENEFITS

Financial Assistance On-Campus Housing (year-round) Counseling Services Basic Health Care Services & Education Summer Bridge Renaissance Scholars Seminar (Life Skills and Transition) Academic Advising Peer Mentoring Tutorial Services Student Activities (Fall Kick-Off, Winter Retreat, Celebration of Excellence, etc.) Leadership Development and Educational Enrichment Opportunities

(Community Service & Financial Literacy Workshops, etc.)

C ELIGIBILITY REQUIREMENTSRenaissance Scholars at Cal Poly Pomona is seeking potential Scholars who meet the followingcriteria:

Demonstrate high motivation and academic potential to succeed in college Must be a current or former foster youth between the ages of 17-24 Qualify for admission to Cal State Polytechnic University, Pomona as a

freshman or transfer student: For CSU admissions criteria and access to the

application for admission, visit: www.c su me n t o r.e d u Qualify for EOP (Educational Opportunity Program)

For income eligibility information, visit: w ww.c sum ent o r.e d u/p l an n ing/ e op Must qualify as an “independent” student under federal financial

aid guidelines For detailed information please visit our website:

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Cal Poly Pomona | Renaissance Scholars

You can use the following checklist to keep track of the materials that are needed to complete your application toCal Poly Pomona and Renaissance Scholars.

ITEM CHECKLIST ITEM DUE DATE

A OFFICE OF ADMISSIONS:□ CSU Undergraduate Application for Admission www.c su me n t o r.e d u October 1-

November 30

P □ $55 application fee (or Request to Waive Admission Application Fee) October 1-November 30

□ SAT I or ACT test scores www.colleg e boa r d. o rg / www.a c t. o rg January 31P □ Student Intent to Register (SIR)/Enrollment Confirmation Deposit (ECD) May 1

□ Official Final High School and/or College transcripts July 15

EDUCATIONAL OPPORTUNITY PROGRAM (EOP):□ EOP Application (Educational Opportunity Program)

Feb 1Complete and submit the online EOP application at CSU Mentor www.csumentor.edu

C Printable EOP Application

h t t p :/ / ww w .cal s tat e .ed u/s a s /docum e n t s / E O P a ppl i c a tio n boo k let . pdf RENAISSANCE SCHOLARS PROGRAM:

□ Renaissance Scholar Application January 31□ Form 1: General Information □ Form 4: Teacher Recommendation□ Form 2: Personal Statement □ Form 5: Personal Recommendation□ Form 3: School Report

□ Copy of High School and/or College transcripts January 31□ Copy of ward of the court documentation January 31 (minute orders, letter from Social Worker, etc.)

N OFFICE OF FINANCIAL AID & SCHOLARSHIPS:□ Free Application for Federal Student Aid (FAFSA) www . faf s a.e d .gov January 1 –

March 2□ Copy of 2011 federal income tax return (IRS Form 1040, 1040A,or 1040EZ) and/or the untaxed Income Verification Form if requested by the Financial Aid Office□ Other documents requested by the Financial Aid Office

□ Cal Grant GPA Verification Form January 1 – March 2

□ California Chafee Grant Application ww w .chafe e .c s a c .ca.gov Check website

E UNIVERSITY HOUSING SERVICES□ Residential Halls/S u i t e s www.d s a.c s u p o m ona. e d u/ u hs Check

website□ University Village www.foundation.csupomona.edu/village Check

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KCONTACT INFORMATION: Website: http : //www . cpp . e du/~ssep / r ena i ss a nce - schola r s / i nd e x . sh t ml L Renaissance Scholars, California State Polytechnic University, Pomona

3801 West Temple Avenue Pomona, CA 91768 Fax: (909) 869-2982Makeda D. Bostic Christina M. JacoboCoordinator Educational CounselorTelephone: (909) 869-3169 Telephone: (909) 869-4603E-mail: m d b os t i c @ c p p . edu E-mail: c mjaco b o @ c p p . edu

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Cal Poly Pomona | Renaissance Scholars Page 1 of 3

Form 1: G e neral I nformation Please print or type

Name Male Female OtherLA S T F I R S T M I D D LE

Preferred Name Telephone Cell/Message A R E A C O D E / N U M B E R A R E A C O D E / N U M B E R

Home Address N U M B E R A N D S T R E E T / APT . NO . C I T Y S T A T E Z I P C O D E

Mailing address(if different from above)

N U M B E R A N D S T R E E T / APT . NO . C I T Y S T A T E Z I P C O D E

E-mail Address

Date of Birth Current Age: Bronco ID Number M O N T H / D A Y / Y E A R A ge

AcademicsSchool you currently attend (or from which you graduated) Date of graduation

School Address A D D R E S S C I T Y S T A T E Z I P C O D E

Previous secondary school(s) attended (grades 9–12):Name City State Dates attended

Have you participated in any of the following educational programs in high school? Please check below:Date/How did this program help you? Date/How did this program help you?

Upward Bound (ILP) Independent Living Program

AVID ESTEP Early Step to Emancipation Program

EAOP (UC) Other Foster Care ExperienceAge entered into Total number Month and yearthe foster care system of care placements to date of emancipation

Number of schools attended while in foster care or out-of-home care: Elementary Middle school High school Case County of Origin: Los Angeles Orange Riverside San Bernardino Other

Social Worker’s Name (1) County Contact #

Social Worker’s Name (2) Agency Name Contact #

Independent Living Program (ILP) Transitional Coordinator’s Name Contact #

Current Living Arrangement: Foster Home Group Home Relative Residential facility Other

Preferred Living Arrangement (2016-2017 academic year): Residence Hall Apartment Relative Other

Contact with biological family: Monthly Several times a year At least once a year

No contact Extended Foster Care or AB12 Eligible Not Eligible In Progress

Not Sure

Cal Poly Pomona | Renaissance Page 2

Form 1: G e neral I nformation (c o nti n u e d)

Please submit your application and all supporting documents by:

DEADLINE: January 31st

(postmarked) Mail to:

Work ExperienceMeans of future financial support (mark all that apply): Employment Financial Aid Other List any job (including summer work) you have held during the past three years (begin with the job you hold or held most recently):

Description of Work Employer Dates of Employment Hours per Week

Total earnings between January 1, 2015 and December 31, 2015: $

Current medical coverage (mark all that apply): MediCal Medicare Private health insurance No health insurance

Other

Are you a Veteran of the US Armed Forces: Yes No

Are you eligible to receive Veterans Benefits Yes No

Activities & AwardsIn the order of importance to you, tell us about those interests or activities to which you have committed significant amounts of timeand energy in high school and/or college. Include any awards or special recognition.

Briefly describe how you currently spend your summer or winter breaks from school. Also, please indicate where you would reside during extended break periods for the 2016-2017 academic year.

More About YouSo what are some of the things that make you who you are? Obviously there is no substitute for getting to know you in person, butyour responses to the topics below can help us to learn a little more about you. Have fun with this.

Favorite book: Favorite keepsake or memento:Favorite song (title/artist): Favorite food:Favorite movie: Favorite place to get away from it all:Favorite TV program: Two adjectives friends would use to describe you:Favorite source of news: Your source of inspiration:Favorite way to relax: The best advice you’ve ever received:






By signing below, I acknowledge the accuracy, honesty, and completeness of the information I supplied for this application.

Signature Date






Information Release Waiver

The Family Education Rights and Privacy Act of 1976, as amended and contained in the Code of Federal Regulations (34CFS99, Subpart D99.30), requires a written and dated consent from any student before disclosing personal identifiable information from the student’s educational/financial records to a third party.For more information about FERPA please visit the Federal Department of Education: www . e d . g o v / po lic y /g e n / r e g/f e rpa /i n d e x . html

By checking this box I agree to the following:

I grant Renaissance Scholars the permission to release ne c e s s ary information provided on my application for the sole purpose of recommending me for potential scholarship opportunities made available through Renaissance Scholars and a third party.

By signing below, I acknowledge that I have read and agree to the terms of the Information Release Waiver.

Name

Signature Date

Photograph/Video Release Waiver

By checking this box I agree to the following:

I grant the University and the Renaissance Scholars program the right and permission to use photographs, film, tape or sound recordings taken of me for use on the website, non-print and print media materials.

By signing below, I acknowledge that I have read and agree to the terms of the Photograph/Video Release Waiver.

Name

Signature Date



(postmarked) Mail to: Renaissance


Form 2: P e rsonal Sta t e ment (Please print or type)

Student InformationName

L AS T M ID D L E FIRST

Home Address N U M B E R AN D S T R E E T / AP T . N O . C IT Y S T AT E Z IP C O D E

Bronco ID Number Phone Number

Please Complete the Following1. SHORT RESPONSE

Please submit a short response for the question below. Use no more than one 8 1/2” x 11” sheet of white paper. Useonly one side of the page. Additional pages will not be accepted. Please type or print your responses using black ink. In the top right corner of the page, type or print your name, Bronco ID # (if applicable), and the words “Short Response.”

o Please tell us briefly why you have decided to apply to the Renaissance Scholars program at Cal Poly Pomona?

2. PERSONAL STATEMENTThe personal statement is an important part of your application to the Renaissance Scholars program at Cal PolyPomona. We use your personal statement to learn more about you as an individual—your talents, experiences, achievements, and points of view. Think of the personal statement as your opportunity to introduce yourself to us. What would you like us to know about you that may not be evident from a review of the rest of your application?

You may want to write about people who have influenced you, situations that have shaped you, difficulties or conflicts with which you have struggled with, goals and hopes you may have for the future, or something else you consider significant. Regardless of what you choose to write about, your personal statement should reflect your own ideas and be written by you alone. Present your ideas in a focused, thoughtful manner. Support your ideas with specific examples. Personal statements comprised of lists of qualities or accomplishments are not useful or effective.

Use no more than two 8 1/2” x 11” sheets of white paper for your personal statement. Use only one side of each sheet. Additional pages will not be accepted. Please type or print your personal statement using black ink. In the top right corner of each page, type or print your name, Bronco ID # (if applicable), and the words “Personal Statement.”

Signature

My signature constitutes a pledge that the short responses and personal statement are accurate and entirely my own work. I understand that if either of those representations is not correct, the Renaissance Scholars program reserves the right to reject my application or to withdraw my offer of admission to the program.

Signature Date





Form 3: School Report (Please print or type)Instructions for the Student

1.Please fill in the student information below.2.If you wish to waive your right of access to this reference, please sign the Information Access section

below.3.Give this form to your high school principal or guidance/college counselor.




School Currently Attending SCHOOL N AM E

School Address N U M B E R AN D S T R E E T / AP T . N O . C IT Y S T AT E Z IP C O D E

Name of school official completing this form

Information AccessUnder the Family Educational Rights and Privacy Act of 1974, an applicant who is admitted to Cal Poly Pomona and who chooses to enroll here may review the university’s records that pertain to him or her alone. If, however, an applicantwishes to obtain confidential recommendations, which will be used for purposes of admission and counseling only, this right of access may be waived. If you wish this teacher reference to remain confidential, please sign below.

“I will not seek access to this confidential recommendation submitted to the Renaissance Scholars Program for the purposes of admission and academic counseling only.”

Applicant’s Signature Date

Instructions for the Principal or Guidance/College Counselor

The student whose name appears above is applying for admission to the Renaissance Scholars program at Cal Poly Pomona. We would appreciate your candid appraisal of the student’s academic performance, intellectual promise, and personal qualities.

Please complete the various sections of this form, including the summary statement about the candidate. If that statement is in the form of a letter, please staple it to this form.

We truly appreciate your assistance in helping us make the best decision possible for the Renaissance Scholars for Fall 2015.

NOTE: If there are anecdotes or examples that illustrate your comments, please use them.We would appreciate it if you would check the ratings and respond to the specific questions, and sign the form before returning it.


Form 3: School Report (co n tin u e d)




Student Characteristics/Motivation Ratings

Outstanding Excellent Good Average Below Average N/A (top few this year) (top 10%) (above average)

Academic motivation Intellectual Creativity Academic Potential

Critical Thinking

Open-mindedness

Self-confidence

Concern for others

Leadership

Work ethic

Emotional maturity

Respect accorded by peers

Selflessness

General Ratings

How would you compare this student to his or her entire class? Please check the single most appropriate rating for each category.

Outstanding Excellent Good Average Below Average (top few this year) (top 10%) (above average)

Academic achievements Extracurricular/community contributions

Character and personal qualities

Overall

How long have you known the student? In what capacity?

This report is based upon Personal observation Other counselors’ Teachers’ Records






(check more than one if applicable): contact with student observations comments






General Evaluation/Summary StatementWe know that young men and women applying to Renaissance Scholars are still growing and developing at this stage in their lives. To help us gain a holistic view of this student, we ask that you provide us with the following information by drawing upon your own experience in working with the student:

1. What particular academic strengths or weaknesses stand out?

2. What particular traits or qualities (either positive or negative) is the applicant noted for?

3. Are there any particular contributions the applicant has made to the school and/or community?

4. Are there any special circumstances in the student’s background that would help us better understand and appreciate his or her academic or extracurricular performance?

To the principal or guidance/college counselorIf there is anything you would like us to know about your school (particular programs offered, the nature of the communityform which it draws its students, any special opportunities you offer or challenges you face, etc.) that might help us better understand the applicants to Cal Poly Pomona’s Renaissance Scholars from your area, please make note of it here.

Name Position or title

Telephone E-mail

Signature Date


Form 4 : T e ac h er Rec o mmen d ation




(Please print or type)Instructions for the Student

1. Please fill in the student information below.2. If you wish to waive your right of access to this reference, please sign the Information Access section

below.3. Give this form to a high school or college teacher who has taught you in one of the following

subjects: English, social studies, mathematics, science, or foreign language.






Name of school official completing this form

Information AccessUnder the Family Educational Rights and Privacy Act of 1974, an applicant who is admitted to Cal Poly Pomona and whochooses to enroll here may review the university’s records that pertain to him or her alone. If, however, an applicant wishes to obtain confidential recommendations, which will be used for purposes of admission and counseling only, this right of access may be waived. If you wish this teacher reference to remain confidential, please sign below.“I will not seek access to this confidential recommendation submitted to the Renaissance Scholars program for the purposes of admission andacademic counseling only.”


Instructions for the TeacherThe student whose name appears above is applying for admission to the Renaissance Scholars Program at Cal Poly Pomona. We would appreciate your candid appraisal of the student’s academic performance, intellectual promise, and personal qualities.

Note: If you have written a letter on behalf of this candidate that responds to the sorts of questions we have asked, it is acceptable simply to attach the letter to this form, complete Question #3, sign the form, and return it to our office.

We truly appreciate your assistance in helping us make the best decision possible for the Renaissance Scholars for Fall 2015.






Recommendation InformationIn what academic subjects have you taught this student? Grade level taught this studentSubject or Course (e.g., 10, 11, 12, college level) Grade earned

How long have you In what context, if any, have you knownknown the student? the student outside the classroom?

1. What are the first words that come to your mind to describe this student?

2. We would like to know what sort of student this applicant is. For instance, what would you tell a colleague to expect from this student by way of participation and performance in class? What one or two characteristics of this student appear to you to be most responsible for his or her achievement in your class?

3. We also would like to know what sort of person this applicant is. For instance, is there a particular trait or personal quality that makes this student stand out in your mind? Are there any special strengths or weaknesses we should take into account? Are there any special circumstances in the student’s background that would help us better understand and appreciate his or her academic or extracurricular performance?

How would you compare this student to his or her entire class? Please check the single most appropriate rating for each category.

Outstanding (top few this year)

Excellent (top

Good (above average)

Average Below Average

Academic achievements

Extracurricular/community contributions

Character and personal qualities

Overall

(Please Print or Type)







Telephone E-mail

Signature Date


Form 5 : Pe r sonal R e c o mmen d ation (Please print or type)Instructions for the Student

1. Please fill in the student information below.2. If you wish to waive your right of access to this reference, please sign the Information Access section

below.3. Give this form to a high school or college teacher, social worker, ILP Coordinator, employer, etc. (NOTE:

Please D O N O T have this form completed by a sibling, foster parent or family member).






Information AccessUnder the Family Educational Rights and Privacy Act of 1974, an applicant who is admitted to Cal Poly Pomona and who chooses to enroll here may review the university’s records that pertain to him or her alone. If, however, an applicant wishes to obtain confidential recommendations, which will be used for purposes of admission and counseling only, this right of access may be waived. If you wish this teacher reference to remain confidential, please sign below.“I will not seek access to this confidential recommendation submitted to the Renaissance Scholars program for the purposes of admission andacademic counseling only.”


Instructions for the Person Writing this Recommendation

Please attach a letter to this form to inform us what you can about the applicant that would help us get to know him or her better. Things such as but not limited to:

•How long have you’ve known the applicant and in what capacity?•Are there particular strengths and/or weaknesses that come to mind?•Particular interests or abilities or talents?•Noteworthy character traits?

References of this sort are most helpful when examples or anecdotal evidence is provided that allows us to better understand why you have described the applicant as you have. Please remember to sign the form and any attachments provided. We appreciate your interest and time in writing on behalf of this applicant.


Telephone E-mail

Signature Date

Please submit your application and all supporting documents by:DEADLINE: January 31st (postmarked)

Mail to: Renaissance Scholars3801 West Temple Ave. Pomona, CA 91768

Documents

Guardian Scholars Applicationssep/documents/Renaissance Scholars... · Web viewola r s 3801 W est T e mple A ve. P o mona, C A 91 7 68 Please submit your application and all supporting