The following application must be complete. Please do not leave any blanks. If a question cannot be answered,
please put N/A in the box. We are committed to honoring the privacy of our applicants. The information provided
by the applicant will be used solely for the evaluation purposes by Renaissance Scholars program staff only.
DISCLAIMER: Acceptance into Renaissance Scholars does not guarantee admission into EOP or Fresno State.
PERSONAL INFORMATION
Name: ___________________________________________________________________________
First
Middle
Last
Preferred Name ________________________________Fresno State ID #: ____________________
Home Address: ___________________________________________________________________
Mailing address
(if different from above) ________________________________________________________________
Phone (home): _____________________ Cell: _______________ Email: ______________________
Date of Birth: _______________________ Age: _________ Gender: _________________________
Ethnicity (optional): Check all that apply
□ American Indian
□ Asian
□ Black, non-Hispanic
□ Bi-racial/Multi-ethnic
□ Latino
(Spanish Origin or Hispanic
□ Pacific Islander
□ White
□ Decline to state
(Tribal enrollment or affiliation)
(Including African American)
FOSTER CARE EXPERIENCE
Name of Social Worker: ________________________________ Phone: _______________________
Were you involved with the independent living skills program?
□ Yes
□ No
Independent Living Program (ILP) Coordinator: ___________________________________________
Are you participating in Extended Foster Care (AB12)?
□ Yes
□ No
Were you in foster care between your 16th and 18th birthday?
□ Yes
□ No
County of Origin: □ Fresno
□Kings
□ Madera
Total years spent in foster care: _______
□ Tulare
□ Other___________
Number of placements while in foster care: _______
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INDEPENDENT STATUS AND ADDITIONAL INFORMATION
Independent Status (check all the apply)
□ Current or former foster youth □ Homeless Youth
□ Emancipated Minor
□ Legal Guardianship
Current Living Situation:
□ Group Home
□ Family/Friend
□ Foster home
□ Orphan
□ Other: ____________
□ Residential Facility
□ Other________
Plan for housing while attending Fresno State:
□ On-Campus
□ Off Campus
□ Relative/Friend
Current Medical Coverage:
□ Medical
□ Private Insurance
□ Other Insurance__________________
□ Other___________
ACADEMICS
Have you submitted an application to the Educational Opportunity Program (EOP) at Fresno State?
(Note: Students admitted to EOP receive priority consideration into the Renaissance Scholars Program)
□ Yes
□ No
School currently attending: ______________________________________________________________
City ____________________________State ______________Cumulative GPA__________
Number of schools attended: Elementary_______ Middle School_______ High School________
Have the participated in any of the following educational programs? Please check below:
□ AVID
□ EOP&S (Community College)
□ Student Support Services
□ College Assistance Migrant Program
□ Independent Living Skills
□ Upward Bound
□ Educational Opportunity Program
□ Talent Search
□ University Migrant Services
CURRENT BARRIERS TO ACADEMIC SUCCESS OR EMPLOYMENT
Your goals are important to us and we want to do everything we can to help you achieve them. Help us by letting
us know if there is anything that might hinder your success here at Fresno State. Checking any of these boxed will
in no way reduce your chances of being selected from for Renaissance Scholars.
Please put an X next to any areas that might affect you:
Need child care
No transportation
Having family problems
No place to live/homeless
Need help getting food
Need help purchasing books/supplies
Coping with a violent relationship
No close family members
Anger Problems
Mental or emotional health issues
History of substance abuse
Criminal Record
Pregnant or parenting youth
Legal problems (probation, court date, etc.)
Self-esteem issues
Other:
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EMERGENCY CONTACTS
Please provide the names of two individuals that can be contacted on your behalf:
Name ______________________________Relationship______________ Phone _________________
Name ______________________________Relationship______________ Phone _________________
□ Check box if you agree to the following terms:
I give the Renaissance Scholars staff permission to contact the social worker(s) listed above to
obtain information on my behalf for professional or academic purposes.
TRUTH STATEMENT
I certify that the information provided on this application is true and accurate to the best of knowledge. I authorize
the Renaissance Scholars staff to contact my current or previous placement agencies to verify my eligibility and
information provided.
__________________________________
___________________
Applicant’s Signature
Date
ADDITIONAL DOCUMENTATION
You must submit documentation of your eligibility for independent status for Renaissance Scholars
through proof of being ward of the court/foster youth, legal guardianship, orphaned, legal emancipation
or proof of homeless status. If you have questions about this documentation or need assistance
obtaining your foster care dependency letter, please contact the Renaissance Scholars office for
assistance. This documentation can be submitted with your application.
Renaissance Scholars Contact information:
(559) 278-1787
[email protected]
TURN IN APPLICATION
You may hand-deliver, mail, or fax your application and support materials to the Renaissance Scholars
office:
Renaissance Scholars Program
California State University, Fresno
Joyal Administration Building, Room 224
5150 North Maple Avenue M/S JA62
Fresno, CA 93740-8026
Fax: (559) 278-1895
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