You must have JavaScript enabled to use this form. *NOTE: This application cannot be saved for later use.  Please make sure you have all required documentation before you begin.  For questions, please call or  email  the Guardian Scholars office at  209-228-2394. Personal Information Net ID * First Name * Last Name * Preferred Name / Nickname * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028 - None -MaleFemaleOther Gender Identity (Optional) Other - None -American Indian or Alaskan NativeCubanPuerto RicanCentral AmericanSouth AmericanGuamanianBlack, non-Hispanic, including African AmericanCambodianChineseJapaneseKoreanHawaiianAsian IndianMexican-American, Mexican or ChicanoLaotianVietnameseThaiOther Southeast AsianFilipinoSamoanOther Latino, Spanish - Origin or HispanicOther AsianOther Pacific IslanderWhiteDecline to StateOther Ethnic Identity (Optional) Other Select all that apply by holding down "Ctrl" when making your selections. - Select -SMLXLXXLXXXLOther Shirt Size Other Contact Information Home Phone * Cell Phone Bobcat E-mail * Personal E-mail * Home Address Street and Apartment * City: * State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: * Mailing Address Street and Apartment * City: * State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: * Emergency Contact Name * Relationship * Phone Number * Foster Care Information I have never been in Foster Care.I am currently in Foster Care in California.I was previously in Foster Care in California, and aged out or emancipated from the system.I am currently in Foster Care in a system outside California.I was previously in Foster Care in a system outside California, and aged-out or emancipated from the system.I was temporarily in foster care, but did not age-out or emancipate from the system.Other Have you ever been in court-ordered foster care? Other - Select -Foster HomeGroup HomeLegal GuardianshipKinship CareProbationCombination of two or moreOther Primary Care Type Other County of Origin * - Select -AlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlennHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMedocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BenitoSan BernadinoSan DiegoSan FranciscoSan JoaquinSan Louis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehamaTrinityTulareTuolumneVenturaYoloYuba Please select the county in which your foster care case was opened. This may be different than the actual county you are/were placed in. Date of Emancipation * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2016201720182019202020212022202320242025202620272028202920302031 Total Years in Foster Care * - Select -<1 Year123456789101112131415161718192021 - Select -1234567891011121314151617181920Other Total Foster Care Placements Other - Select -12345678910Other Number of Schools Attended in Care Other - Select -At least once a monthAt least once a yearSeveral times a yearNo contactOther Biological Family Contact Other Social Worker Name * Social Worker Phone Number * Are You Eligible for AB-12 Funding? * - Select -YesNoNot Sure Are You Eligible for a Chafee Grant? * - Select -YesNoNot Sure Are You Eligible for ILP? * - Select -YesNoNot Sure ILP Coordinator Name * ILP Coordinator Phone Number * Employment and Financial Information Are You Employed? * - Select -YesNoSeasonal Financial Supports * Employment AB-12 Funding Financial Aid Scholarships Family Assistance Food Stamps Unemployment Insurance Disability Insurance Savings (Select all that apply) Where? * - Select -DormsSolo ApartmentShared ApartmentSolo HouseShared HouseLive with RelativeOther Planned Living Other Total Income in 2014 * Medical Information - Select -Medi-CalPrivate Health InsuranceNoneNot SureOther Medical Coverage Other Academic Information - Select -FreshmanTransferOther Class Level Other Date of Graduation * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028 Cumulative GPA * Extracurricular Activities * Tell us about what you like to do for fun and how you stay motivated. Documents Letter of Recommendation * Please attach a letter of recommendation from a social worker, ILP worker, teacher, coach, pastor, friend, or family member.Files must be less than 50 MB.Allowed file types: gif jpg png pdf doc docx. Personal Statement * Please attach a 2 page essay discussing how your foster care experience has shaped your outlook for your higher education goals.Files must be less than 50 MB.Allowed file types: gif jpg png pdf doc docx. Letter of Dependency * Please attach a letter of dependency from your Social Worker or ILP Coordinator verifying your foster care status. This letter should include your full name, date of birth, placement county, CWS-CMS case number, beginning and end dates of care, and type of care.Files must be less than 50 MB.Allowed file types: gif jpg png pdf doc docx. Signature I Acknowledge * Submit that by clicking "Submit" I validate the accuracy of this document and agree to the terms of the Guardian Scholars Program at UC Merced. 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