CalWORKs Fall 2016 Scholarship Application
1. Complete Scholarship Application
2. Sign Release of Authorization Form
3. Personal Statement (Typed, 2 double-spaced page max.)
Your statement should address the following:
What challenges have you had to overcome to pursue your educational goal?
What CalWORKs resources (tutoring, orientation, counseling, workshops) have you used? and
How have they helped you become a successful student?
4. Completed application must be submitted by:
Friday, October 28, 2016
No later than 4:00pm to the Cerritos College CalWORKs office
All Applicants MUST:
1. Be a current and active Cerritos College CalWORKs student
Must have current semester Eligibility and a Continuing Student Form (dated Aug. - Dec. 2016)
2. Must be currently enrolled in the Fall 2016 semester
3. Must have submitted a Work-in Progress (WIP) Form for the Fall 2016 semester
Work-In Progress (WIP) Form is due the week of Oct. 3-7, 2016
4. Must have a minimum grade point average (G.P.A) of 2.0
Note: Incomplete and/or late applicaons will not be considered
CalWORKs Scholarship Applicaon
Student ID Number: ______________________ Date: __________________________
Last Name: ____________________ First Name: _________________________
Address: _____________________________________________________________________________
City, State, Zip Code: ___________________________________________________________________
Home Phone: _________________________ Cell Phone: _____________________
Email Address: ________________________________________________________________________
Area of Study (Major): __________________________________________________________________
Educaonal Goal: (Circle All that apply)
AA Degree Cercate Transfer
Transfer Goal (If applicable): UC CSU OTHER:_______________
Expected Graduaon Semester/Year: _______________
Received by: _____________________
Date: _____/______/_______
Approved date: __________________
Denied date: _________________
Summer _____
Fall ____
Oce Use ONLY
Release Authorizaon Form
Please complete and sign the following statement to authorize Cerritos College CalWORKs Department to
use your picture and quotes from your Cerritos College CalWORKs Portraits of Success Scholarship Applica-
on Packet.
I, _______________________________ hereby give the Cerritos College CalWORKs Department a free
nonexclusive, royalty-free, irrevocable, world-wide license to use my picture and statements submied on
the CalWORKs Portraits of Success Scholarship Applicaon in a manner that the Cerritos College CalWORKs
Department whishes including: copying, eding, distribung, performance, display, and promoonal pur-
poses, and in any medium that the Cerritos College CalWORKs Department wishes.
I agree to release and discharge the Cerritos College CalWORKs director and sta from any liability for any
use, misappropriaon or disclosure of any informaon including but not limited to, all claims or damages
for defamaon, insult, invasion of privacy or any other claim based upon the use by the Cerritos College
CalWORKs Department.
______________________________________ _________________________
Student Signature Date