Please provide your complete personal and academic information. All fields marked as mandatory must be completed for your application to be processed.
Full Legal Name
Student ID Number
Date of Birth
Primary Email Address
Phone Number
Current Mailing Address
Emergency Contact Information
Emergency Contact Full Name
Emergency Contact Relationship
Emergency Contact Phone
Emergency Contact Email
Academic Program Details
Institution Name
Program of Study
Major/Concentration
Current Year/Semester
Current Enrollment Status
Full-time (12+ credits)
Part-time (6-11 credits)
Less than part-time (<6 credits)
Not currently enrolled
Current Credit Hours Enrolled
Living Situation
On-campus housing
Off-campus rental housing
Living with family
Temporary housing
Other
Are you an international student?
Please provide your visa status and any restrictions on employment or financial assistance:
Do you have any dependents (children, elderly parents, etc.) who rely on your financial support?
Please describe your dependent(s) and their financial needs:
Provide a detailed account of the emergency situation that has caused your financial hardship. Be specific and include all relevant dates and circumstances.
Primary Type of Emergency
Medical emergency or health crisis
Death of immediate family member
Natural disaster (fire, flood, earthquake, etc.)
Sudden loss of housing
Job loss or significant reduction in income
Victim of crime or accident
Family emergency requiring travel
Other (please specify)
Please describe the nature of your emergency in detail:
Date Emergency First Occurred
Detailed Description of Emergency Circumstances
Immediate Financial Impact
Has this emergency directly impacted your family or support network's ability to assist you financially?
Explain how your family's financial ability to support you has been affected:
Has this emergency caused a disruption to your current employment or income sources?
Describe the income disruption, including your employer's name, your position, and the extent of lost income:
Expected Duration of Financial Hardship
Less than 1 month
1-3 months
3-6 months
6-12 months
More than 12 months
Indeterminate at this time
Do you have insurance coverage that applies to this emergency?
Describe your insurance coverage and what expenses have been or will be covered:
Explain why insurance coverage is not available for this emergency:
Prior to this emergency, how would you rate your overall financial stability?
Very unstable
Unstable
Somewhat stable
Stable
Very stable
Provide a detailed, itemized breakdown of your financial needs resulting from this emergency. Include all relevant expenses and any amounts already covered by other sources. You must upload supporting documentation for each category where applicable.
Total Amount of Emergency Grant Requested
Detailed Budget Breakdown
Expense Category | Total Amount Needed | Amount Already Covered | Outstanding Balance (Auto-Calculated) | Payment Due Date | Priority Level (1=Low, 5=Critical) | ||
|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | ||
1 | Tuition and Mandatory Fees | $0.00 | $0.00 | $0.00 | 1/15/2025 | ||
2 | Housing/Rent | $0.00 | $0.00 | $0.00 | 1/1/2025 | ||
3 | Medical/Dental Expenses | $0.00 | $0.00 | $0.00 | 1/10/2025 | ||
4 | Transportation/Emergency Travel | $0.00 | $0.00 | $0.00 | 1/20/2025 | ||
5 | Food and Essential Supplies | $0.00 | $0.00 | $0.00 | 1/5/2025 | ||
6 | Books and Academic Materials | $0.00 | $0.00 | $0.00 | 2/1/2025 | ||
7 | Childcare or Dependent Care | $0.00 | $0.00 | $0.00 | 1/15/2025 | ||
8 | Utilities (electricity, internet, phone) | $0.00 | $0.00 | $0.00 | 1/8/2025 | ||
9 | Other Emergency-Related Expenses | $0.00 | $0.00 | $0.00 | 1/25/2025 | ||
10 |
Supporting Documentation Upload
Upload Tuition/Fee Statement or Invoice
Upload Housing/Rent Agreement or Eviction Notice
Upload Medical Bills or Insurance Statements
Upload Travel Itinerary or Transportation Receipts
Upload Proof of Income Loss (termination letter, pay stubs)
Upload Bank Statements (last 30 days)
Upload Any Other Relevant Documentation
What alternative funding sources have you explored or applied for?
Personal savings
Family assistance
Bank loan
Credit cards
Crowdfunding
Other institutional emergency funds
Government assistance programs
Community organization aid
None of the above
How much of your personal savings have you applied to this emergency?
How much financial assistance has your family provided?
Describe the status of your bank loan application:
What is the total credit limit you have available on cards?
List other institutional funds you have applied for and their status:
List government programs you have applied for and their status:
List community organizations you have contacted for assistance:
If awarded, what is your intended timeline for using these emergency funds?
What will be the impact on your academic progress if this emergency funding is not provided?
This section captures your current financial aid status and academic record to provide context for the emergency grant evaluation.
What types of financial aid are you currently receiving? (Select all that apply)
Merit-based scholarship
Need-based grant
Student loans
Work-study employment
Graduate assistantship
Fellowship
Veterans benefits
Employer tuition assistance
None
Are you receiving any private or external scholarships?
List each scholarship, the awarding organization, and the annual amount:
Are you currently employed in a work-study, research, or teaching position?
Describe your position, weekly hours, and monthly income:
Explain your current employment situation and why you are not working:
Current Academic Standing
Good standing
Academic probation
Academic warning
Suspended
Dismissed
Not applicable (first semester)
Current Cumulative GPA (if applicable)
Credit Hours Enrolled in Current Term
Rate your attendance record for the current semester
Are you currently facing any academic or disciplinary sanctions?
Describe the nature of the sanctions and their status:
Academic Advisor Full Name
Academic Advisor Email
Which campus support services have you utilized? (Select all that apply)
Academic tutoring
Counseling services
Career services
Disability services
Financial aid advising
Student health services
Food pantry/emergency aid office
None of the above
This section is to be completed by the Financial Aid Committee and Bursar's Office upon review of your application.
Application Submission Date
Committee Review Date
Committee Review Notes and Assessment
Committee Decision
Approve full requested amount
Approve partial amount
Deny application
Defer pending additional documentation
Approved Amount:
Approved Partial Amount:
Reason for Denial:
Additional Documentation Required:
Bursar's Office Clearance: Are there any outstanding holds or balances that would prevent disbursement?
Describe the holds or balances and resolution plan:
Applicant Digital Signature
Financial Aid Committee Chair Signature
Bursar's Office Representative Signature
Decision Notification Date
Is an appeal available if the applicant disagrees with the decision?
Appeal Deadline Date:
Additional Comments or Recommendations
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