Fillable 2016-17 Undergraduate Application Form 2016-17_Undergraduate_Application_Form.pdf

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2016-17 Undergraduate Application Form 2016-17_Undergraduate_Application_Form.pdf

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The 2016-17 Undergraduate Application Form 2016-17_Undergraduate_Application_Form.pdf form is 19 pages long and contains:

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Country of origin: US
File type: PDF

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Instructions:
• Download form and complete online
• Print and sign the application, authorization for transcripts, and the permission form using blue or black ink
• Deadline for Submission to Kennedy-King by February 5, 2016 (the earlier the better)
• Submit the completed forms to your community college’s College Scholarship Office as noted in the Undergraduate Letter.
Application
First Name
Middle
Last Name
Current Address
City
State
Zip
Mailing Address (if different)
City
State
Zip
Email Address:
Gender"
Male"
Female
Marital Status"
Single"
Married
Divorced /
Separated
Ethnic Group"
Black"
Latino/a"
Native US Pacific Islander#
enter tribal or island affiliation#
___________________________"
Native American***/Alaskan#
enter tribal affiliation if checked#
___________________________"
*** Include copy of registration from Bureau of
Indian Affairs if Native American if you have one.
Date of Birth
Place of Birth
Military Service"
Yes
No
Dependents"
Yes" No
Names
Ages
Dependents
Relationship
(e.g. son, daughter)
Have you successfully completed at least 12 transferable units of course work within
12 months prior to the scholarship deadline at Contra Costa, Diablo Valley or Los
Medanos Colleges?
Yes No
Are you currently attending a four-year college/university?
Yes No
If so, how many units have you completed and/or are currently enrolled?
Number of Units
When do you expect to transfer as a junior to a four-year college/university?
Fall 2016 Spring 2017
Completed"
Transferable Units:
Transferable Unit Grade"
Point Average (GPA):
Overal Grade"
Point Average (GPA):
If you successfully complete your currently enrolled units, will you have completed all
required courses with sufficient units to transfer with junior standing next fall?
Yes No
Page of 1 13
© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
P.O. Box 2643 ● Martinez, CA 94553-0264 ● www.kennedyking.org
Undergraduate
2016 Scholarship Application Form
5 digit
5 digit
And...
Application Form Continued
The “Educational Plan” in your Counselor’s Verification Form must list all courses (names, numbers & units)
yet to be completed to be eligible for transfer with junior standing and asterisk (*) required subject courses
College Applications And Estimated Total School And Living Cost (List Up To 5)
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© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
Anticipated four year college major:
Educational and/or vocational goals after graduation:
College
Have you
applied?
Estimated School Year Costs
Yes"
No
$
Yes"
No
$
Yes"
No
$
Yes"
No
$
Yes"
No
$
How will you pay for the junior year of the four year college you plan to attend and all other expenses you may
incur while in college? List every source and amount. Give potential school year amounts and asterisk (*)
those you have been awarded already or believe likely to be received.
If you
currently have any loans, complete the following section.
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© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
College
Current School Year!
$ Granted Student
Will you apply for
your junior year?
$ Expected to
receive for your
junior year
Pell Grant/FSEOG Fed Supplementary Ed Opportunity
Grant
$
Yes"
No
$
Cal Grant A and/or B (including Dream Act)
$
Yes"
No
$
Military Service Benefits
$
Yes"
No
$
Other State, Federal, College, Private and/or any other
grants or scholarships
$
Yes"
No
$
Income & support from work & all other sources
by you and your spouse
$
Yes"
No
$
Parents, family or any other source of funds
$
Yes"
No
$
Loans
$
Yes"
No
$
Will you live with Parents or Relatives while you attend
school at a 4 Year College or University?
Yes"
No
Name of Organization
Amount
Amount if Any in Default
$ $
$ $
$ $
If you are not applying for Pell and/or Cal Grants or if you are not filing a FAFSA and/or Cal Grant Dream
Act application, explain why not?
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© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
Source of Income & All Other Support
You
Your Spouse
Parents
(not required if applicant
is 25 years old or older)
Employment position
Yearly earnings
$
$
$
All other income and support - food stamps
$
$
$
All other income and support - welfare
$
$
$
All other income and support - child support
$
$
$
All other income and support - other
$
$
$
Net value of savings, investments, and real or other
property owned
$
$
$
Cars owned by you and/or your spouse
Brand#
Model"
#
Year
Brand#
Model"
#
Year
Number and ages of parents’ dependents
What is your “Expected Family Contribution” from your Student Aid Report (“SAR”)? $  
Please attach a copy of your SAR or FAFSA application or Cal Grant Dream Act application (sections B-E) if
you have not received a SAR. If you have not filed a FAFSA or Cal Grant Dream Act application, your
Community College Financial Aid Office (“FAO”) can assist you. If you do not provide a SAR, FAFSA or Cal
Grant Dream Act application, please provide your family’s tax returns or other specific information relevant to
your need or explain failure to do so in the
explanatory notes section that follows.
Applicants should also address financial support & need in detail in their
autobiographical essay.
Community Service provided by applicant to or through organizations or otherwise
I prepared this application and the information it contains is true and complete to the best of my knowledge and
belief:
Applicant Name (printed)
Applicant signature in black or blue ink
Date
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© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
Expected family contribution
Expected family contribution from your student Aid Report (SAR) $
List Community Service Organizations (list up to 5)
Est. Total Hours
Worked
From!
(MM/DD/YY)
To
(MM/DD/YY)
1
Hrs:
2
Hrs:
3
Hrs:
4
Hrs:
5
Hrs:
Notes
1. The number of Kennedy-King scholarships awarded each year is dependent upon the amount of money
raised. Kennedy-King is an all-volunteer organization with no paid staff.! Over!ninety percent!of the
financial!contributions from the community go directly to scholarships. Unfortunately, each year we receive
many more applications from deserving students than we can fund. Consequently, selection for a scholarship is
quite competitive. If we are not able to fund a scholarship for you, do not be discouraged. Know that we wish
you success in pursuing and achieving your educational goals.
2. All complete and timely filed applications will be reviewed. Students selected for interviews (and those not
selected) will be notified by e-mail by the end of February. The scholarship selection interviews will only be
held Saturday morning, March 19, 2016, at DVC.! No alternate arrangements will be made.
Please do not apply if you know you cannot attend.
3. If you are selected for an interview, note the following.
•
Each interview is scheduled for 20 minutes with a panel of three interviewers.
•
The interview is designed to give the interviewers an opportunity to get to know you and ask questions.
•
You can and should supplement and explain anything you believe may not have been clear in your
application or which you want to be sure the interviewers remember about you.
•
Present yourself as though you are interviewing for a job.
•
Dress professionally.
4. You will be notified by e-mail as to the outcome of your interview within approximately one week of the
interview.
5. Kennedy King Scholarship funding will commence in the fall, 2016 (or spring, 2017) after acceptance,
transfer with Upper Division (junior) standing and enrollment in a qualifying four-year college or university.
No advance funding will be provided.
Page of 6 13
© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
Explanatory Notes To Application Answers
Insert Here:      
Autobiographical Essay
Provide below a two - three-page autobiography in the space provided at the end of this form.
Assuming you meet the qualifications for a Kennedy King Scholarship (see cover letter to applicants), your
application will be evaluated upon the following criteria:
1. Demonstrated Financial Need
2. Academic Achievement & Potential
3. Community Service & Involvement
4. Personal Attributes (e.g., Character, Integrity, Responsibility, Commitment, Determination, Hard Work,
Achievements, Hardships Overcome, Life’s Goals, etc.)
To the extent that you believe your application may not otherwise fully reflect the above, you should specifically
address those subjects in your autobiographical essay.
In light of these criteria, and other factors you believe relevant, answer the question: why do you believe you
should be given a Kennedy King Scholarship?
Publication Summary
We need a "Publication Summary" in approximately 75 words or less that tells your story as set forth in your
Autobiographical Essay. This may be used for publication in the Kennedy King dinner program and for
distribution to news media and the Internet if you are selected for a scholarship. It is the primary instrument we
use to show our donors that their money is being used to assist needy and worthy scholarship recipients who
have worked hard, overcome difficulties, contributed to their communities and have the strength, character and
potential to do well in college and after.
It is an important part of your application.
Please do not!use the Publication Summary to thank family, friends, teachers and others, or to proclaim broad
social platitudes as such language will be edited out of the!summary.
We reserve the right to edit your summary,
as we believe appropriate in our absolute discretion and to modify it with information extracted from other parts
of your application including your autobiographical essay. Begin Summary with your
Full Name and
Community College.
Complete this in the space provided at the end of this form.
Page of 7 13
© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
Authorizations
The scholarship applicant is responsible for obtaining all transcripts and financial documents that must
accompany the scholarship application. Please sign the following authorizations that give the Kennedy-King
Memorial College Scholarship Fund, Ltd., and its authorized representatives, the right to receive such
information. Please list all colleges (including all CCCCD and all other community colleges) and universities
attended.
Financial Authorization
I give permission to the Kennedy-King Memorial College Scholarship Fund, Ltd. (“Kennedy King”), and its
authorized representatives, to receive information about my financial status from the above colleges and
universities and those I later attend where I received or was qualified to receive Kennedy King Scholarship
funds.
Authorization For Transcripts
I give permission to the Kennedy-King Memorial College Scholarship Fund, Ltd., and its authorized
representatives, to receive a transcript of my courses, units and grades from the above colleges and universities
and those I later attend where I received or was qualified to receive a Kennedy King Scholarship funds,
including specifically final graduation transcripts, awards, and graduation status and information.
Page of 8 13
© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
Colleges and Universities Attended
Student ID Number
From!
(MM/DD/YY)
To
(MM/DD/YY)
Applicant Name (printed)
Applicant signature in black or blue ink
Agreement to provide Authorization for
Transcripts
Date
Applicant Name (printed)
Applicant signature in black or blue ink
Agreement to provide Financial
Authorization
Date
Permission Form
I hereby give my permission to the Kennedy-King Memorial College Scholarship Fund Ltd. and its board members, officers, agents
and designees, including photographers and the Contra Costa Community College District (collectively “Kennedy-King”) to
photograph, videotape and interview me, and to use the foregoing and information from the application I submit, including my
pictures, success story, quotes and/or other information (collectively the “Materials”) in connection with Kennedy-King’s scholarship
awards and fund raising activities. These activities may include advertising, promotion, news stories and releases, web, Internet, video
and television activities, etc.
I understand and agree that the absolute right and permission here granted is unlimited as to use of the Materials for the purposes
described above, and that:
1. These Materials will become the property of Kennedy-King and will not be returned;
2. The use of the Materials will be without any compensation to me, my heirs or assigns;
3. Kennedy-King may edit, alter, copy, exhibit, publish and/or distribute the Materials;
4. I waive the right to inspect or approve the finished product in which the Materials appear;
5. I release and hold harmless Kennedy-King, the photographer, videotaping person, their officers, employees, agents, and designees
from any liability, claims, demands, causes of action, or attorneys fees regarding the use of these Materials and my image or
likeness, including for violation of any personal or proprietary right I may have in connection with such use.
I am 18 years of age or older, have read and understand this release, and sign this release voluntarily.
Parent or Guardian of Applicant if Under the Age of 18:
I represent that I am a parent/guardian of the minor who has signed the above release and I hereby agree that we shall both be bound
thereby.
Applicant Name (printed)
Applicant signature in black or blue ink "
Agreement to this permission form.
Date
Parent or Guardian Name (printed)
Parent or Guardian signature in black or
blue ink providing agreement to this
permission form.
Date
Parent or Guardian Contact Information
Current Address
City
State
Zip
Mailing Address (if different)
City
State
Zip
Home Phone Number:
Mobile Phone Number:
Page of 9 13
© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
(555) 555-5555
(555) 555-5555
Autobiographical Essay Form
Essay"
First Name
Middle
Last Name
Community College
Page of 10 13
© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
Contra Costa
Diablo Valley
Los Medanos
Essay Continued (Page 2)"
Page of 11 13
© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
Essay Continued (Page 3)"
Page of 12 13
© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
Publication Summary
First Name
Middle
Last Name
Community College
Page of 13 13
© 2015 Kennedy-King Memorial College Scholarship Fund Ltd. Updated October 28, 2015
Contra Costa
Diablo Valley
Los Medanos
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