CalWORKs Summer 2016 Scholarship Application
Complete Scholarship Application
Sign Release of Authorization Form
Personal Statement (Typed-written, 2 double spaced pages max.)
Your statement should address the following two (2) questions:
1. How has the Cerritos College Program helped you meet your educational goals?
2. What Challenges have you had to overcome to pursue your educational goal?
Completed application must be submitted to the Cerritos College CalWORKs office
no later than 4:00p.m on:
Thursday June 16, 2016
Please Note: Incomplete and/or late applicaons will not be considered
All Applicants MUST:
1. Be a current and active Cerritos College CalWORKs student
*must have provided a Summer 2016 (May-August) Verification of Benefits & Continuing Student Form
2. Must be currently enrolled in a Summer Session
*either Summer 1, Summer 2, or both
3. Must have completed at least one (1) semester at Cerritos College
4. Have a current GPA of 2.5 or better
5. Have good academic standing with Cerritos College
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: (Check all that apply)
AA Degree Cercate Transfer
If you chose the Transfer Goal: (check all that apply)
UC CSU OTHER:_______________
Expected Compleon Date: _____________________ Graduaon Semester/Year: _______________
Received by: _____________________
Date: _____/______/_______
Oce Use ONLY:
Entered by: _____________________
Date: _____/______/_______
Release Authorizaon Form
Please complete and sign the following statement to authorize Cerritos College CalWORKs Depart-
ment 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 Cerri-
tos College CalWORKs Department whishes including: copying, eding, distribung, performance,
display, and promoonal purposes, and in any medium that the Cerritos College CalWORKs Depart-
ment 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