ŶĚŽǁĞĚScholarship Agreement Form
Please complete this form to establish a new ĞŶĚŽǁĞĚscholarshipwith the Contra Costa College (CCC)Foundation. A signed Agreement Form and a minimum contribution ŽĨΨϮϱ͕ϬϬϬis required to establish and maintain aŶĞŶĚŽǁĞĚ scholarship.
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Donor Name(s): ______________________________________________________________________ Full Address: _________________________________________________________________________ Email Address: ____________________________________ Phone: _____________________________ Name of Scholarship: ______________________________________________________________ Number of Students Awarded Annually (number of recipients each year): ____________________ Scholarship Award Amount (amount each recipient will receive): $__________________________ Scholarship Criteria
Answer the questions below to indicate the criteria that students must meet in order to be considered for this scholarship. Please note that CCC and the CCC Foundation follow Title VI of the Civil Rights Act, therefore do not discriminate on the basis of race, color, gender, and national origin. Skip any question that does not apply.
Academic Major Required: ________________________________________________________________ Student Status (check all that apply): ᵼIncoming Freshman ᵼContinuing Student ᵼTransferring Student Enrollment Status: ᵼFull-time (12+ units) ᵼHalf-time (6+ units) ᵼLess than half-time (under 6 units) Educational Status (check all that apply):
ᵼFirst-generation (first in their family to attend college) ᵼRe-entry (did not attend college directly after high school) Minimum GPA Required: ___________
Is Financial Need Required or Preferred? ᵼNo ᵼYes, required ᵼYes, preferred Is School Involvement Required or Preferred (e.g., school clubs, athletics, student government, etc.)? ᵼNo ᵼYes, required ᵼYes, preferred
Is Community Service Required or Preferred (e.g., volunteerism, activism, etc.)? ᵼNo ᵼYes, required ᵼYes, preferred
Matt Rodriguez
1000 Gateway Avenue, San Pablo, CA 94806
[email protected] 510.215.3016
San Pablo Forward Scholarship
10 $1000
Any
2.5 In the space below, briefly describe any other criteria not already indicated above. You may also use this space to provide a description of the scholarship donor, memorial, etc.:
___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Donor Certification
By signing below, I, the scholarship donor/custodian, understand all of the following:
x A signed
ŶĚŽǁĞĚScholarship Establishment Form and a minimum contribution and fund balance of $Ϯϱ,000 isrequired to establish and maintain aŶĞŶĚŽǁĞĚ scholarship account. x Scholarship donation checks should be made payable to the Contra Costa College Foundation noting the name of the scholarship in the memo section of the check. Checks can be mailed to CCCF, 2600 Mission Bell Drive SAB 218, San Pablo, CA 94806. Online donations can be made securely at:
https://tinyurl.com/donate-to-cccf-now (pick Other and then list the name of scholarship). __________________________________ ________ __________________________ _____________ Donor/Custodian Name (please print) Donor/Custodian Signature Date ____________________________________________ ________________ Foundation Director Signature Date
Timing of Scholarship Application Cycle and Selection Process By October 31 New scholarships must be established and funds received November 1 CCC Foundation Scholarship Application opens ƌŽƵŶĚ February 18 CCC Foundation Scholarship Application deadline March Scholarship applications are reviewed and scored by the Scholarship Review Committee
April Each selected applicant is notified of their scholarship selection May Donors learn of student recipients and have chance to connect with students
August Scholarship funds are disbursed to student recipients after verifying that all scholarship criteria are met and the student is enrolled For more information, please contact Sara Marcellino, CCC Foundation Executive Director, at [email protected] or 510-215-3805. CCC Foundation’s Tax ID is 94-6135368. A one-time 4% sustainability fee will be assessed on all restricted donations to help provide ongoingsupport ƐŽƚŚĂƚ the CCC FoundationĐĂŶĐŽŶƚŝŶƵĞƚŽƐƵƉƉŽƌƚŵŽƌĞƐƚƵĚĞŶƚƐ͘
City of San Pablo resident (jurisdictional city boundaries), has community service, volunteerism, civic engagement, mentions equity Matt Rodriguez