RENAISSANCE
SCHOLARS
APPLICATION: FALL 2016
EMPOWERING FORMER FOSTER YOUTH THROUGH HIGHER EDUCATION
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 the
nation’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 MISSION
We 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.
T
PROGRAM BENEFITS
1. Financial Assistance
2. On-Campus Housing (year-round)
3. Counseling Services
4. Basic Health Care Services Education
5. Summer Bridge
6. Renaissance Scholars Seminar (Life Skills and Transition)
7. Academic Advising
8. Peer Mentoring
9. Tutorial Services
10. Student Activities (Fall Kick-Off, Winter Retreat, Celebration of Excellence, etc.)
11. Leadership Development and Educational Enrichment Opportunities (Community Service Financial Literacy Workshops, etc.)
C ELIGIBILITY REQUIREMENTS
Renaissance Scholars at Cal Poly Pomona is seeking potential Scholars who meet the following
criteria:
□ 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.csumentor.edu
□ Qualify for EOP (Educational Opportunity Program)
For income eligibility information, visit: www.csumentor.edu/planning/eop
□ Must qualify as an “independent” student under federal financial aid guidelines For detailed information please visit our website: www.dsa.csupomona.edu/ssep
Cal Poly Pomona | Renaissance Scholars
You can use the following checklist to keep track of the materials that are needed to complete your application to
Cal Poly Pomona and Renaissance Scholars.
ITEM CHECKLIST ITEM DUE DATE
A OFFICE OF ADMISSIONS:
□ CSU Undergraduate Application for Admission www.csumentor.edu 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.collegeboard.org / www.act.org January 31
P □ 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 1
Complete and submit the online EOP application at CSU Mentor www.csumentor.edu
C Printable EOP Application http://www.calstate.edu/sas/documents/EOPapplicationbooklet.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.fafsa.ed.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 www.chafee.csac.ca.gov Check website
E UNIVERSITY HOUSING SERVICES
· Residential Halls/Suites www.dsa.csupomona.edu/uhs Check website
· University Village www.foundation.csupomona.edu/village Check website
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CONTACT INFORMATION: Website: http://www.cpp.edu/~ssep/renaissance-scholars/index.shtml
L Renaissance Scholars, California State Polytechnic University, Pomona
3801 West Temple Avenue Pomona, CA 91768 Fax: (909) 869-2982
Makeda D. Bostic Christina M. Jacobo
Coordinator Educational Counselor
Telephone: (909) 869-3169 Telephone: (909) 869-4603
E-mail: E-mail:
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Cal Poly Pomona | Renaissance Scholars Page 1 of 3
Form 1: General Information
Please print or type
Name ¨ Male ¨ Female ¨ Other
LA 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
Academics
School 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 Experience
Age entered into Total number Month and year
the 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
Work Experience
Means 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 Awards
In the order of importance to you, tell us about those interests or activities to which you have committed significant amounts of time
and 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 You
So what are some of the things that make you who you are? Obviously there is no substitute for getting to know you in person, but
your 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.ed.gov/policy/gen/reg/ferpa/index.html
· By checking this box I agree to the following:
I grant Renaissance Scholars the permission to release necessary 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
Cal Poly Pomona | Renaissance Scholars Page 1 of 1
Form 2: Personal Statement
(Please print or type)
Student Information
Name
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 Following
3. 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. Use
only 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?
4. PERSONAL STATEMENT
The personal statement is an important part of your application to the Renaissance Scholars program at Cal Poly
Pomona. 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
Cal Poly Pomona | Renaissance Scholars Page 1 of 3
Form 3: School Report
(Please print or type)
Instructions for the Student
• Please fill in the student information below.
• If you wish to waive your right of access to this reference, please sign the Information Access section below.
• Give this form to your high school principal or guidance/college counselor.
Student Information
Name
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
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 Access
Under 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 and academic counseling only.”