UNOFFICIAL SCHOLARSHIP APPLICATION

1/7/2021 Scholarship Application 2021-2022 - New Item

https://spforms.coconino.edu/sites/scholarships/Lists/Scholarship Application 20212022/NewForm.aspx 1/6

Middle Namee

Last Name *

Mailing Address *

City *

State *

Please use two-character abbreviation (Example: AZ for Arizona)

Zip Code *

Phone Number *

Example: 928-555-5555

Terms of UseBy checking this box and continuing to complete this application, you confirm that you have readand agree to the Terms as stated below. Some CCC scholarships, waivers and grants are funded inpart or in whole with Arizona state monies. These funds are governed by Arizona State laws. Aperson who is not a citizen of the United States, who is without lawful immigration status andwho is enrolled as a student at any university under the jurisdiction of the Arizona Board ofRegents or at any community college under the jurisdiction of a community college district in thisstate is not entitled to tuition waivers, fee waivers, grants, scholarship assistance, financial aidtuition assistance or any other type of financial assistance that is subsidized or paid in whole or inpart with state monies. The Office of Student Financial Aid (OSFA) cross references thisapplication with the Domicile Affidavit-Residency Statement and other documentation that youprovided to Registration and Enrollment Services (RES) and/or the Free Application for FederalStudent Aid (FAFSA). CCC is required to report to the State of Arizona the number of studentswho apply for scholarships and other forms of financial aid and are denied due to not beinglawfully in the U.S. in a status eligible for the financial assistance. Failure to turn in the DomicileAffidavit-Residency Statement or other required documentation with RES may disqualify you forfinancial assistance that contains state monies. By checking this box, I understand the OSFA willview my eligibility status based on the Domicile Affidavit-Residency Statement and otherdocumentation that I provided to the RES and/or the FAFSA. I also understand that CCC isrequired to report to the State of Arizona the number of students who apply for scholarships andother forms of financial aid that include state monies and are denied due to not being in a lawfuland eligible status for such aid. I give my consent to CCC to release my academic and financialaid data, as well as scholarship application data to the CCC Foundation, other departments in thecollege, and scholarship granting organizations who assist in the application and administrationof scholarships and financial aid.

CCC ID# * @00Starts with the @ symbol followed by eight numeric characters.

CCC Comet ID *

Starts with the first initial of your first name and first inital of your last name. (example: AB123)

Birthdate *

MM/DD/YYYY Format

CCC Email Address * @students.coconino.eduUse only your CCC email address. This is CCC's form of communication to the student.

Gender * MaleFemale

Tuition Residency Classification * In-District State ResidentWhat is your tuition residency classification?

High School Graduate * Yes, I have graduated or will graduate from high school by July 1, 2021No, I will not graduate from high school by July 1, 2021

Options: In-District State Resident, Out-of-District State Resident, Western Undergraduate Exchange-WUE, Out of State, DACA/non-resident, Pending Visa/non-resident

This copy of the CCC Scholarship Application is a reference only to help draft and edit application responses. You must submit your official application on-line by

March 11, 2021.First Name

UNOFFICIAL SCHOLARSHIP APPLICATION

CCC Foundation Scholarship applications are being reviewed. Recipients will be notified in May for the 2021-2022 academic year.



Cumulative High School GPA 0.00What is your cumulative high school GPA at the end of the fall 2020 semester?

High School in Coconino County YesNo

Did you graduate from a Coconino County high school?

High School Name

Year Graduated High School

What year did you or will you graduate high school?

Degree/Certificate at CCC *To be considered for certain scholarships, you must be degree or certificate seeking and have amajor declared at CCC. For more information regarding degrees or certificates visit our Degreesand Certificates page at: https://www.coconino.edu/degrees-and-certificates

Major at CCC *

Current CCC Cumulative GPA 0.00

Fall Hours at CCC *Anticipated Credit Hour Enrollment Fall 2021 at CCC

Spring Hours at CCC *Anticipated Credit Hour Enrollment Spring 2022 at CCC

CCC Location *CCC Location that you will primarily attend for 2021-2022.

GED * YesNo

If you did not graduate from high school did you complete a Graduate Equivalent Degree (GED)?

Choose "No" if you did graduate from high school or if this question does not apply to you.

Year Graduated with GED

Previous College #1

Name of most recently attended College

Previous College #1 GPA 0.00

Previous College #2

Previous College #2 GPA 0.00

Anticipated Graduation *When do you anticipate graduating from CCC?

Transferring * YesNo

Will you be transferring to a 4-year institution?

CCC2NAU * YesNo

Have you been accepted into the CCC2NAU program?

FAFSA * Yes, I have submitted a 2021-2022 FAFSA.No, I have not submitted a 2021-2022 FAFSA.

Have you submitted a 2021-2022 Free Application for Federal Student Aid (FAFSA)? SomeFoundation scholarships are need-based, to determine if a student is eligible for these types ofscholarships they must complete a 2021-2022 FAFSA.

Expected Family Contribution (EFC)

If you have submitted your 2021-2022 FAFSA, please provide your Expected Family Contribution(EFC). This information is required to be considered for need-based scholarships.

Options: Associate of Arts (AA) Degree, Associate of Business (ABus), Associate of Fine Arts (AFA), Associate of Science, Associate of Applied Science (AAS), Certificate Program, Not degree or certificate seeking

See Course Catalog or your Program web page

Options: 5 or less, 6-8, 9-11, 12+

Options: 5 or less, 6-8, 9-11, 12+

Options: Lone Tree/Fourth St., Grand Canyon, Page/Lake Powell, Online


https://www.coconino.edu/degrees-and-certificates



Repeating a Course at CCC * YesNo

Do you intend to repeat a course in fall 2021 that you were previously unsuccessful (received agrade D, F, W) in at CCC?

If yes, you are encouraged to complete the additional Specialized Scholarships Essay for the Re-Boot Scholarship at the end of this application.

4-H Membership * YesNo

Were you a member of the 4-H Club within the past 15 years?

Veteran Status * YesNo

Are you an Veteran of the US Armed Services who received an honorable discharge?

If Yes, which branch?

Disability * YesNo

If you have a disability, we recommend that you register with CCC Disability Resources at 928-226-4323. We also enourage you to complete the additional Specialized Scholarships Essay forthe Eric Pellatz Scholarship at the end of this application.

Disability Explanation

If 'Yes', please explain:

Registered with CCC Disability Resources * YesNo

Nursing * YesNo

Have you been accepted into the CCC Nursing program or have you declared AAS-Pre-HealthCareers as your major?

If yes, you are encouraged to complete the additional Specialized Scholarships Essay for JasonKurtz Nursing Scholarship at the end of this application.

Year in Nursing Program

Construction Technology Certificate * YesNo

Are you seeking a Construction Technology Certificate?

If yes, you are encouraged to complete the additional Specialized Scholarships Essay for theLoven Contracting Building Relationships Scholarship at the end of this application.

Are you a single parent? * YesNo

Juvenile Probation * YesNo

In the past 25 years, were you on probation with Coconino County Juvenile Court before your18th birthday? Checking YES may qualify you for additional scholarship funds.

If yes, you are encouraged to complete the additional Specialized Scholarships Essay for the StepUp Scholarship at the end of this application.

Native American YesNo

Are you Native American?

Native American Tribe




If yes, please specify which tribe:

LeChee Chapter * YesNo

Are you a member of the LeChee chapter of the Navajo Tribe in Page?

Armed Forces * YesNo

Are you a member of the Arizona National Guard who received a purple heart citation on or afterSeptember 11, 2001 or a former member of the Arizona National Guard who was medicallydischarged from the Arizona National Guard due to an injury or disability suffered during statusunder Title 10, United States Code, in weekend training status, in annual training status or inresponse to a state of emergency declared by the governor? If yes, you are eligible for a fulltuition waiver scholarship provided for in this section as defined by ASRS 15-1808. Funds can onlybe applied towards tuition. If you meet this criteria, please submit supporting documentation tothe Office of Student Financial Aid at the Lone Tree campus. Please include your Name andCCCID# on the documentation and clearly write on the document that it is in support of yourscholarship application.

Law Enforcement * YesNo

Are you the child or spouse of a peace officer, correctional officer, fire fighter, emergencyparamedic, or National Guard member killed in the line of duty? If yes, you qualify for a fulltuition waiver. This tuition waiver is also for disabled National Guard members and disabledUnited States armed forces member as defined by ASRS 15-1808. Funds can only be appliedtowards tuition. If you meet this criteria, please submit supporting documentation to the Office ofStudent Financial Aid at the Lone Tree campus. Please include your Name and CCCID# on thedocumentation and clearly write on the document that it is in support of your scholarshipapplication.

Scholarships * YesNo

Did you receive any scholarship(s) last year?

SCHOLARSHIPS: (1) Name of Scholarship

Include your two most significant scholarships.

(1) Scholarship Amount: $ 0

(2) Name of Scholarship

(2) Scholarship Amount: $

HONOR/AWARD

List the name of the honor/award

Year(s) Received Honor/Award

(Example: '2020-2021' or '20, '21)

EXTRACURRICULAR ACTIVIES: (1) Name of Organization/Activity

High School and College Clubs, Organizations and Offices held, Extracurricular Activities.

(1) Year(s) Participated in Organization/Activity

(Example: '2020-2021' or '20, '21)

(2) Name of Organization/Activity

(2) Year(s) Participated in Organization/Activity

COMMUNITY SERVICE: (1) Name of Agency

(Church or other religious groups, Big Brothers Big Sisters, Youth Groups, Volunteer Activities,etc…) List up to two activities of service.

(1) Position of Job you held

(1) When did you serve in this position?

(Example: '2020-2021' or '20, '21)




(1) Average Hours per Month Served

(2) Name of Agency

(2) Position of Job you held

(2) When did you serve in this position?

(2) Average Hours per Month Served

EMPLOYMENT

Please list your current or most recent employment.

Your Job Title

Year(s) Employed

(Example: 2019, 2020, 2021)

Student Essay *

The Student Essay section is required and is separate from the Specialized Scholarship Essaybelow. Write an essay about what distinguishes you from other scholarship applicants. Your essayshould also include a clear and concise statement about your educational and career goals. It isrecommended that you use Microsoft Word and utilize the spell check, grammar check and wordcount features and proofread carefully. Both quality of writing and content are important. Thisessay is weighted heavily in the selection process by the Scholarship Committee. Limit your essayto 1000 WORDS. If you exceed 1000 words, your scholarship application will not be considered.

Specialized Scholarships * I do not wish to apply for an additional specialized scholarshipBanjo Billy Scholarship for Underserved Native American StudentsJason Kurtz Nursing ScholarshipEric Pellatz Memorial ScholarshipLoven Contracting Building Relationships ScholarshipRe-Boot ScholarshipSRP Navajo Scrubber ScholarshipStep-Up Scholarship

The Banjo Billy Scholarship for Underserved Native American Students requires the student toexplain the need for the scholarship.

The Jason Kurtz Nursing Scholarship requires that you write about your experience or knowledgeof oncology and/or hospice nursing fields.

The Eric Pellatz Memorial Scholarship requires that you write about how your disability impactsyou as a college student and how the award will assist you in your educational pursuits.

The Loven Contracting Building Relationships Scholarship requires you to answer the question: Iam seeking the construction technology certificate because…

The Re-Boot Scholarship requires you to explain your plan for success when re-taking the class.

The SRP Navajo Scrubber Scholarship requires that you describe how your educational goals willhave a positive impact on the Navajo Nation concerning economic, social, medical, or educational




development.

The Step-Up Scholarship requires that you describe how you have overcome the challenges youfaced while on probation. You may also include interests and activities important to you.

Do not exceed 250 words, or your essay will not be considered.

Specialized Scholarships Essay

If you selected an additional Specialized Scholarship in the question above, please insert your 250word essay that is specific to that scholarship here. Do not exceed 250 words or your applicationwill not be considered.

You have completed the CCC Scholarship Application, click Submit Click "Submit" Button BelowAfter clicking Submit, you will receive an email from us confirming receipt of this application. Ifyou don’t get an email, there is a problem and you should call us at 928-226-4219. If you clickSubmit and the application will not submit, then you did not complete all of the required fields inthe application.

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hereUNOFFICIAL SCHOLARSHIP APPLICATION

This copy of the CCC Scholarship Application is a reference only to help draft and edit application responses. You must submit your official application on-line.

If you have drafted, edited, and reviewed your application responses, you are ready to enter and submit your official application.

This copy of the CCC Scholarship Application is a reference only to help draft and edit application responses

in a word processing program. You must submit your official application on-line.

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UNOFFICIAL SCHOLARSHIP APPLICATION