Fillable 2021-2022 Student Application (Evergreen Valley College)

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2021-2022 Student Application (Evergreen Valley College)

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2021-2022 Student Application
The Karl S. Pister Leadership Opportunity Program
enables outstanding
UC-qualified junior-level community college students to complete their
undergraduate studies at UC Santa Cruz. The program provides a
scholarship of up to $20,000 distributed over two years, mentoring and
academic support, and assistance finding paid or volunteer summer work
experience. Recipients will be selected by the UCSC chancellor from
nominees submitted by the presidents of participating community colleges.
One scholarship is available for each college.
Each president may nominate up to three students who:
u
Show exceptional achievement through academic and
extracurricular accomplishments despite adverse socioeconomic conditions;
u
Demonstrate an involvement in activities that assist and improve the lives of others;
u
Exhibit outstanding leadership qualities that reflect the ideals of the Pister Program;
u
Because of financial need, would not otherwise be able to attend UC Santa Cruz;
u
Are qualified for fall 2021 admission to UCSC as a new junior-level transfer student.
Application Instructions
u
Fill out the application completely. Incomplete applications will not be considered.
u
Apply for fall 2021 admission to UC Santa Cruz by submitting the UC Application for Undergraduate Admission and Scholarships by
the extended deadline of December 4, 2020: apply.universityofcalifornia.edu
u
Apply for financial aid by submitting the Free Application for Federal Student Aid (FAFSA) or California Dream Act Application by
March 2, 2021
.
Students on a non-immigrant visa (e.g., F-1, J-1, etc.) are not eligible for this award.
u
Collect two letters of recommendation. At least one letter must be from a faculty member. The other letter should be from an
individual who is able to comment on such areas as extracurricular activities, leadership skills, commitment and dedication, etc.
u
Obtain transcripts from all colleges attended (unofficial copies are acceptable).
u
Keep a copy of your application.
u
Submit the following items in one packet
to your community college
:
1. scholarship application with personal statement included
2. two letters of recommendation
3. all college transcripts (unofficial copies are acceptable)
Application deadline: February 5, 2021
Participating Community Colleges
Cabrillo College Foothill College Monterey Peninsula College
Cañada College Gavilan College San José City College
College of San Mateo Hartnell College Skyline College
De Anza College Mission College West Valley College
Evergreen Valley College
Please keep this information sheet for your records.
Karl S. Pister Leadership Opportunity Program
University of California, Santa Cruz
2021-2022 Application
Personal Information
Full legal name_________________________________________________________________________________
Any other names that you go by ___________________________________________________________________
Mailing address______________________________________ City_________________ State_____ Zip_________
Permanent address (if different from above)_________________________________________________________
Primary phone number (select:
☐
cell
☐
mobile
☐
home
☐
other)________________________________________
Alternate phone number (select:
☐
cell
☐
mobile
☐
home
☐
other)________________________________________
Email address______________________________
What community college are you currently attending?__________________________________________________
Have you applied for fall 2021 admission to UC Santa Cruz? (you must have applied for admission during the filing period
to be eligible)
☐
yes
☐
no UCSC Student ID Number (obtained after you apply)________________________________
Student’s Financial Information
Have you filed the Free Application for Federal Student Aid (FAFSA)? (you must file a FAFSA or Dream Act Application to
be eligible)
☐
yes
☐
no Date submitted_________________________
Occupation_________________________________ Employer_____________________________________
Current monthly income from employment $_____________________ Hours worked per week____________
Projected 2020 annual income (applicant) $_____________________ (spouse) $_______________________
List all other sources and amounts of income, including family assistance:_______________________________
__________________________________________________________________________________________
List all scholarships/grants that have been applied for or received:_____________________________________
__________________________________________________________________________________________
List major debts and other expenses you will incur per month during the school year:
Debt Amount Debt Amount
________________________________________ _______________________________________
________________________________________ _______________________________________
________________________________________ _______________________________________
Total indebtedness (including above) per month $_________________________
List the dependents you will support between July 1, 2021 and June 30, 2022:
Full names of dependent(s) Age
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Karl S. Pister Leadership Opportunity Program
University of California, Santa Cruz
!
University of California, Santa Cruz
Parent/Guardian Information
(To be completed by dependent students only)
Parent 1/Legal Guardian______________________________________________________________________
Address___________________________________________________________________________________
Employer______________________________________________ Position held_________________________
Annual income $__________________________________ Own or rent residence?______________________
Parent 2/Legal Guardian______________________________________________________________________
Address___________________________________________________________________________________
Employer____________________________________________ Position held___________________________
Annual income $__________________________________ Own or rent residence?______________________
List any other dependents receiving financial support from family:
Name Age Relationship to applicant
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Personal Statement
Instructions: In a separate document, please respond to the
following five questions. Your response to each question
should be limited to 250-500 typed words. Include your name
and the words “Personal Statement” at the top right-hand
corner of each page, and submit your responses with this
application.
1. What is your intended major, and why have you chosen
this field?
2. This program is intended for students who have
demonstrated excellent academic and extracurricular achievement despite adverse socioeconomic conditions.
Considering these criteria, please describe your educational and personal history.
3
. Students who receive this scholarship have been involved in activities that assist and improve the lives of ot
hers.
Please describe your commitment in this area, as well as your involvement in any extra-curricular activities that have
developed your leadership skills.
4
. The scholarship will be awarded to a student who, because of financial need, wou
ld not otherwise be able to attend UC
Santa Cruz. Please describe your financial situation.
5. Please ex
plain any special circumstances you feel the committee should be aware of when evaluating your application.
Certification
I certify that the information reported on this application, to the best of my knowledge, is true and correct.
I authorize my community college, UC Santa Cruz, and the Karl S. Pister Leadership Opportunity Program Advisory
Committee to release the information in this application to scholarship committees both on and off campus and to review
my academic transcripts and financial aid application.
Signature_________________________________________ Date_______________________
If I am selected as a recipient, I authorize my community college and UC Santa Cruz to publicize any relevant
scholarship and biographical information and/or publish photographs.
Signature__________________________________________ Date_______________________
The University of California, in accordance with applicable Federal and State law and University policy, prohibits discrimination against or harassment of any person and does not discriminate
on the basis of race, color, national origin, religion, sex, gender identity, pregnancy, physical or mental disability, medical condition (cancer related or genetic characteristics), genetic
information (including family medical history), ancestry, marital status, age, citizenship, sexual orientation, or service in the uniformed services as defined by the Uniformed Services
Employment and Reemployment Rights Act of 1994. The University also prohibits sexual harassment. Inquiries regarding the University’s student-related nondiscrimination policies may be
directed to Student Judicial Affairs, (831) 459-1738. Inquiries regarding the UCSC Policy on Sexual Assault, the UC Policy on Sexual Harassment, and Procedures for Reports of Sexual Assault(s)
and Sexual Harassment and/or violations of Title IX may be directed to the Title IX Coordinator/Sexual Harassment Officer, (831) 459-2462.
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2021-2022 Student Application (Evergreen Valley College)

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Completed 2 February 2021

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