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SCHOLARSHIP PLANNING COMMITTEE

SURVEY OF PROBABLE 2001 GRADUATES

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I believe the youth listed below will be graduating from High School in 2001, is in out of home care, and will/may need scholarship assistance as they pursue higher education.

I.  Identifying information
Youth’s Name / Date of Birth
State Number / SS#
Address / Phone #
City / State / Zip
CSW’s Name / Phone #
Has the youth been referred to the Independent Living Program (ILP)? / Yes / No
If so, ILP Coordinator’s Name
What high school does the youth attend?
What is the youth’s current GPA? / Expected high school graduation date
Is the youth planning to pursue higher education (College/Trade School)? / Yes / No
If yes, what University/College/Trade School does the youth plan to attend?
Expected college major?
Is the youth in out of home care (relative, group or foster homes and residential facilities)?
Yes / No
If no, was the youth in out of home care after age 16? / Yes / No
Does this youth have any problem with the University/College/Trade School knowing that they
are a part of the Federal Independent Living Program (ILP) or ward of the court?
Yes / No

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After completing Section I, please send or FAX your information to:

Caroline Christian, Scholarship Coordinator

5601 West Slauson Avenue, Suite 125, Culver City, CA 90230

(310) 642-1672 or FAX (310) 410-2590

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II. When the youth receives the following documents, please forward them immediately
to the CSW, ILP Coordinator and Scholarship Coordinator.

¨  Acceptance letter, proof of registration

¨  Financial aid award (FAA) letter and signed FAA indicating that youth has accepted FAA offer

¨  Report of youth’s anticipated school expenses (tuition, fees, housing, etc.)

¨  Information regarding acceptance of non-DCFS scholarships and the amount

Signature of Contact Person / Telephone # / Date