The Molly Adams Scholarship Application
2013-2014
The Molly Adams Scholarship provides “aid in the ability of handicapped children” to attend college.
Students who submit completed applications and other required documents by the deadline will be
automatically considered for the Mt. San Jacinto scholarships administered by Mt. San Jacinto
College.
Requirements:
 Complete the MSJC Scholarship Application typed or neatly printed in blue or black
ink.
 For the Fall 2013 and Spring 2014 semester, student must be enrolled in a minimum of 6
credit units and have a minimum cumulative GPA of 3.0.
 Student must be permanent residents of Riverside or San Bernardino Counties.
 Must have financial need.
 Complete Financial Statement. Financial need is required for some scholarships and the
financial statement must be completed and submitted with your application form.
 Attach copies of your unofficial transcripts from all schools that you attended.
 Attach two (2) current Applicant Evaluation Forms.
 Request two individuals, such as teachers, employers, or community leaders who are
familiar with your career goals, to complete this form.

Submit your scholarship application and all required documentation to the Foundation Office drop
box located in the Student Service Building Lobby. San Jacinto Campus Building 1150 or Menifee
Campus Building 100. You can also mail your scholarship application to: MSJC Foundation Office
1499 N. State Street San Jacinto, Ca. 92583 by the deadline of Friday, October 4, 2013 at
12:00pm.
Respond to the following essay questions. Do not submit any other document or statement.
1. Major/Goals: Describe why you selected your major area of study and your future
academic and career goals.
2.
Adversity/Challenges: Describe any adversity or challenges you have overcome or
anticipate in pursuit of your educational goals.
APPLICATION DEADLINE IS FRIDAY, October 4, 2013 by 12:00 noon
Decisions of the scholarship committees are final. Eligibility does not guarantee a scholarship.
Application Deadline is FRIDAY, October 4, 2013 at 12:00 noon. Late applications will not be accepted.
Applications must be date stamped by the financial aid clerks by the deadline OR mailed applications post
marked 10/04/13 will be accepted.
The Molly Adams Scholarship Application
2013-2014
PERSONAL INFORMATION
Name:
_____
LAST
FIRST
MIDDLE
Current Mailing Address:
_____
NUMBER
Phone Number: (
STREET
)
APT.#
CITY
Birth Date:
Zip
__
_____
MSJC I.D #:
Last High School Attended: ______________________________________
Name of High School
State
Graduation Date
Colleges attended other than Mt. San Jacinto College
Name of College
_____________________________
_____________________________
_____________________________
Units
_______
_______
_______
Dates
Cumulative GPA
___________
___________
___________
ENROLLMENT PLANS: Do you intend to register full-time in the following semesters at MSJC (check all
applicable semesters)?
Fall 2013_______
Spring 2014_______
Are your registration fees & books currently being paid by a program or someone other than yourself?
Yes/ No Program:
Amount $:
Are you a single parent with dependent children living with you?
Yes
No
Are you a re-entry student (out of school at least one year)?
Yes
No
Do you have a disability? If yes, please describe briefly:
_
Yes
No
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Application Deadline is FRIDAY, October 4, 2013 at 12:00 noon. Late applications will not be accepted.
Applications must be date stamped by the financial aid clerks by the deadline OR mailed applications post
marked 10/04/13 will be accepted.
FINANCIAL STATEMENT
Many scholarships include financial need as a criterion. This form must be completed for you to be
considered for financial need based scholarships. It is essential that this form reflect a true picture of
your household finances. Please be as candid as possible. Report all income in yearly figures (monthly
x 12) for the calendar 2012.
Income information for 2012
APPLICANT’S HOUSEHOLD SIZE
(Please do not include roommates)
ANNUAL HOUSEHOLD INCOME
Note: indicate income received for the calendar year 2012 only
APPLICANT’S/SPOUSE’S INCOME (if applicant currently married)
Income/wages
$
(student) $
(spouse)
Child support received $
(student) $
(spouse)
Alimony received
$
(student) $
(spouse)
Social Security
$
(student) $
(spouse)
Military housing
(benefit amount)
$
(student) $
(spouse)
Other income
$
(student) $
(spouse)
PARENTS’ INCOME (if applicant under 24 and unmarried)
This information must be included even if you do not live with your parents
Income/wages
$
Child support received $
Alimony received
$
Social Security
$
Military housing
(benefit amount)
$
Other income
$
FOR OFFICE USE ONLY
TOTAL HOUSEHOLD INCOME FOR 2012 $____________
FAFSA Total
$____________
Application Deadline is FRIDAY, October 4, 2013 at 12:00 noon. Late applications will not be accepted.
Applications must be date stamped by the financial aid clerks by the deadline OR mailed applications post
marked 10/04/13 will be accepted.
COLLEGE EDUCATIONAL GOAL
MSJC Educational Goal:
A.A. Degree ___
Certificate ___
Transfer ___
MAJOR
___ ADMIN OF JUSTICE
___ ENGINEERING
___ PHILOSOPHY
___ ANTHROPOLOGY
___ ENGLISH
___ PHOTOGRAPHY
___ ART
___ ENVIRONMENTAL SCIENCE
___ PHYSICAL ED.
___ ASTRONOMY
___ GEOGRAPHY
___ PHYSICS
___ AUTO TECHNOLOGY
___ HEALTH SCIENCE
___ POLITICAL SCIENCE
___ BIOLOGY
___ HISTORY
___ PSYCHOLOGY
___ BUSINESS
___ LIC. VOC. NURSING
___ SOCIOLOGY
___ CHEMISTRY
___ MATHEMATICS
___ TEACHING
___ COMPUTER SCIENCE
___ MUSIC
___ THEATRE ARTS
___ ECONOMICS
___ NUTRITION
___ OTHER (SPECIFY)
___ ELECTRONICS
___REGISTERED NURSING
________________________
Non-completed Nursing pre-requisites
Are you currently enrolled in prerequisites for the Nursing program? Yes/No
If Yes, check the semester(s) in which you are enrolled.
1st semester
___
2nd semester
_
3rd semester _______
4th semester ______
Completed Nursing pre-requisites
If you have completed the nursing prerequisites and are currently enrolled in the Nursing program, check the semester
in which you are enrolled:
1st semester
_
2nd semester
____
3rd semester _____
4th semester ____
Career Goal:
Expected Date of Graduation from Mt. San Jacinto College:
_____
Month
Year
Do you plan to be a teacher when you complete your education?
Yes
No
Do you already have an Associate’s Degree (A.S. or A.A.)?
Yes
No
Are you transferring as a junior in the Spring 2014?
Yes
No
If yes, have you applied for Admission?
Yes
No
If yes, have you been accepted?
Yes
No
Name of the college you plan to attend in the Spring 2014 IF NOT MSJC: _________________
Application Deadline is FRIDAY, October 4, 2013 at 12:00 noon. Late applications will not be accepted.
Applications must be date stamped by the financial aid clerks by the deadline OR mailed applications post
marked 10/04/13 will be accepted.
COMMUNITY INVOLVEMENT
List on/off campus club or organizational activities to which you volunteered
your assistance in the past two years.
NOTE: Do not include organizations where you are employed, received compensation, or earned college credits.
1. Name of Organization
Contact Person
Title
Phone
How many volunteer hours a week do (or did) you provide?
Volunteer Period Beginning Date
Ending Date
2. Name of Organization
Contact Person
Title
Phone _
How many volunteer hours a week do (or did) you provide?
Volunteer Period Beginning Date
Ending Date
3. Name of Organization
Contact Person
Title
Phone _
How many volunteer hours a week do (or did) you provide?
Volunteer Period Beginning Date
Student Offices Held
Ending Date
Awards and Recognitions
Application Deadline is FRIDAY, October 4, 2013 at 12:00 noon. Late applications will not be accepted.
Applications must be date stamped by the financial aid clerks by the deadline OR mailed applications post
marked 10/04/13 will be accepted.
ESSAY ADVERSITY AND CHALLENGES
Responses must be typed.
(Attach to your completed scholarship form)
Describe any adversity or challenges you may overcome or anticipate in pursuit of your
educational goals.
Application Deadline is FRIDAY, October 4, 2013 at 12:00 noon. Late applications will not be accepted.
Applications must be date stamped by the financial aid clerks by the deadline OR mailed applications post
marked 10/04/13 will be accepted.
ESSAY MAJOR AND GOALS
Responses must be typed.
(Attach to your completed scholarship form)
Describe why you selected your major area of study and your future academic and career
goals.
Application Deadline is FRIDAY, October 4, 2013 at 12:00 noon. Late applications will not be accepted.
Applications must be date stamped by the financial aid clerks by the deadline OR mailed applications post
marked 10/04/13 will be accepted.
List any scholarship(s) that were awarded to you in Fall 2012- Spring 2013 academic year.
1.________________________________________________
2.________________________________________________
3.________________________________________________
4.________________________________________________
5.________________________________________________
6.________________________________________________
Please do not write below this line.
____________________________________________________________________________
For Office Use Only
MSJC Units Completed______
Total Units Completed_______
Cost of Attendance 2011-12:
Awarded Financial Aid for 11/12:
(Eligible for Financial Aid Y/N)
Other Institutional Units______
Fall 2013 Units______
$____________________
$____________________
If no, reason why_______________
Unmet Need:
$__________
Application Deadline is FRIDAY, October 4, 2013 at 12:00 noon. Late applications will not be accepted.
Applications must be date stamped by the financial aid clerks by the deadline OR mailed applications post
marked 10/04/13 will be accepted.
MSJC Molly Adams Scholarship Applicant Evaluation Form
To The Evaluator: Scholarship applicants must submit an Evaluation Form when applying for scholarships from at least
two qualified individuals. The Evaluation form must include your name, title and contact information. The Evaluation
Forms must be submitted by the applicant at the same time as they submit their scholarship application. Please return
the Evaluation to the student in plenty of time for them to meet the deadline. You may also write a recommendation in
letter format if you choose.
__________________________________________________________
Name of Applicant
_____________________________
Student ID#
1. How long have you known the student and in what capacity?
2. Please rate the applicant on the following in comparison with other students of the same
level:
Exceptional
General Academic Ability
Above
Average
Average
Below
Average
No
Information
Motivation and Initiative
Quality of Work
Willingness to Learn
Imagination and Creativity
Dependability/Responsibility
Social Skills/Leadership
Ability
Potential to Succeed
3. Overall endorsement of applicant:
Highly Recommend:________ Recommend:________ Recommend with reservations:________
4. Optional: Please provide any additional comments about the applicant on a separate page.
For example: Strengths and accomplishments, background and experiences, family
responsibilities, extenuating circumstances and why you recommend this applicant for the
scholarship. This will assist the committee and/or donors evaluate this applicant.
X_______________________________
Evaluator’s Signature
___________________
Date
Application Deadline is FRIDAY, October 4, 2013 at 12:00 noon. Late applications will not be accepted.
Applications must be date stamped by the financial aid clerks by the deadline OR mailed applications post
marked 10/04/13 will be accepted.
MSJC Molly Adams Scholarship Applicant Evaluation Form
To The Evaluator: Scholarship applicants must submit an Evaluation Form when applying for scholarships from at least
two qualified individuals. The Evaluation form must include your name, title and contact information. The Evaluation
Forms must be submitted by the applicant at the same time as they submit their scholarship application. Please return
the Evaluation to the student in plenty of time for them to meet the deadline. You may also write a recommendation in
letter format if you choose.
__________________________________________________________
Name of Applicant
_____________________________
Student ID#
1. How long have you known the student and in what capacity?
2. Please rate the applicant on the following in comparison with other students of the same
level:
Exceptional
General Academic Ability
Above
Average
Average
Below
Average
No
Information
Motivation and Initiative
Quality of Work
Willingness to Learn
Imagination and Creativity
Dependability/Responsibility
Social Skills/Leadership
Ability
Potential to Succeed
3. Overall endorsement of applicant:
Highly Recommend:________ Recommend:________ Recommend with reservations:________
4. Optional: Please provide any additional comments about the applicant on a separate page.
For example: Strengths and accomplishments, background and experiences, family
responsibilities, extenuating circumstances and why you recommend this applicant for the
scholarship. This will assist the committee and/or donors evaluate this applicant.
X_______________________________
Evaluator’s Signature
___________________
Date
Application Deadline is FRIDAY, October 4, 2013 at 12:00 noon. Late applications will not be accepted.
Applications must be date stamped by the financial aid clerks by the deadline OR mailed applications post
marked 10/04/13 will be accepted.
STUDENT CERTIFICATION
Financial need may be considered in determining eligibility. It must be emphasized that
eligibility for scholarships is mainly based on your ability to meet scholastic and other
criteria as set forth by the scholarship donors. The information you supply on your
scholarship application is recognized by the college to be confidential and you agree
that the college may reveal or forward the contents of your application to the MSJC
Foundation committee members and/or other reviewing committees. Any disclosure of
confidential information associated with any application to individuals not directly
associated with the evaluation process is prohibited. Signature is required for your
application to be considered.
I,
certify that all information given in this
application and other documents is true and complete to the best of my knowledge. If
asked by an authorized official of MSJC, I agree to give proof of income, which may
include a copy of my (and spouse’s) and/or parent’s 2012 U.S. Income Tax Transcript. I
also realize that any false statement or failure to give proof of income when asked may
cause the denial of my scholarship application. I understand that the information
requested on this application is confidential. I authorize Mt. San Jacinto College to
release enrollment and financial data to scholarship donor(s). MSJC may use the
information I have provided for publicity purposes.
Print Name
Applicant’s Signature
Date
Application Deadline is FRIDAY, October 4, 2013 at 12:00 noon. Late applications will not be accepted.
Applications must be date stamped by the financial aid clerks by the deadline OR mailed applications post
marked 10/04/13 will be accepted.