Fillable Application for Student Emergency Funds

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Application for Student Emergency Funds

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The Application for Student Emergency Funds form is 2 pages long and contains:

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  • 2 check-boxes
  • 39 other fields

Country of origin: US
File type: PDF

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Application for Student Emergency Funds
Purpose
The Central Virginia Community College Student Emergency Fund is designed to address exceptional financial
hardship faced by CVCC students that could impact their continued enrollment. Examples of types of
emergencies to consider: house fire, medical issues, assistance with temporary housing for a student left
homeless, etc. Mental Health issues are to be determined by the Student Accessibilities Coordinator,
Community Connections Coordinator, or Dean of Student Success and will not go to the Student Emergency
Fund Committee. The referral will be made directly to the Foundation Office, once the assessment is done.
Mental Health funding also may be used by the Threat Assessment Team if a mental health assessment is
needed to determine if a student can remain on campus. Mental Health funding will only be used if the
student does not have insurance.
Conditions
• Funds may not be used for tuition or books.
• Payment will be made directly to the company/business owed or gift cards will be provided.
• Emergency Fund application requests may be made up to $250. A student may only apply once a
semester for emergency funds.
• Grant recipients MUST write a letter or email of thanks to the Educational Foundation about how the
grant money will help them to stay in college, complete their program, and achieve their goals.
Emergency funds will not be released until the Educational Foundation receives the thank you letter.
Eligibility
To receive funding, students must have a minimum 2.0 GPA and be enrolled in six (6) credits or enrolled in a
Workforce program and successfully passing.
Instructions
1. The student must complete the Student Information section on the reverse side of this application
and attach copies of the bill(s) to be paid, if applicable.
2. The student’s instructor/counselor must complete the Instructor/Counselor Recommendation
section on the reverse side of this application.
3. Instructor/Counselor will submit this form to a member of the Student Emergency Fund Committee.
4. The Educational Foundation will contact the committee member regarding approval of the
application.
Foundation Use Only
Grant Approved ☐Yes ☐No Amount $__________________ __________________
Form of Funding (gift card, payment of bill, etc.) _____________________________________________________________ ________
Signature:
This form cannot be changed without the permission of the CVCC Educational Foundation.
Instructor/Counselor Recommendation (someone other than the SEF Committee member signing)
Instructor/Counselor Name: ____________________ ______ Program: _____________________________________________
Currently Enrolled in __________Credits Current Grade: _______________________________________
Attendance: ________% Potential for success: ________________________________
Comments: __________________________________________________________________________________________ ___
Instructor/Counselor Signature: _____ ________________________________________________________________________
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Student Information
Name: _______________________________________ Date: _____________________________ ______________________
Student ID Number: ______________________ Daytime Phone: __________________________________________
Number of Dependents: _________________________ Marital Status: ___________________________________________
Amount Requested: $________________ for ____________________________ (rent, utilities, car repair, food, gasoline, etc.)
Please indicate all sources of income, e.g., employment, spouse employment, child support, welfare, worker
retraining, food stamps, etc.
Monthly income: $________________ __
Sources(s): ______________________________________________________________________________________ __________
Employer Name: ____________________________________ Your Position: ___________________________________________
List below your monthly expenses (rent, mortgage payment, utilities, food, gas, car payment/insurance, etc.)
_______________________________________________________________________________________________________
____________________________________________________________________________________________ __ ________
Provide a brief description of your exceptional need/circumstances below and what you have done to find
other funding:
______________________________________________________________________________________________________ ___
____________________________________________________________________________________________________ _____
___________________________________________________________________________________________________ ______
By signing this application below, I certify that: 1) the information on this application (front and back) is
complete, true, and correct; 2) I am in need of this funding to continue my education at CVCC; 3) I authorize
the release of my financial aid information; and 4) I will write a thank you letter addressed to the Foundation
Board before any emergency funds will be released.
_______________________________________________ _______________________________________________
Student Signature Date
Financial Aid Information
Financial Aid Disbursement after Tuition $__________________________ Date: __________________________ _______
Student has completed a FAFSA: ☐Yes ☐No Eligible: ☐Yes ☐No
Comments: ___________________________________________________________________________________________ ___
_________________________________________________________________________________________________ _______
Financial Aid Signature: _________________________________________________________ ____________________________
This form cannot be changed without the permission of the CVCC Educational Foundation.
Student Emergency Fund Committee Recommendation
☐Recommended: Type (circle) Em. Funds, Food Card, Gas Card, Mental Health) Amount $_______ __
☐Not Recommended
Comments: ____________________________________________________________________________________________ _______
_________________________________________________________________________________________ _________________
Committee Member Signature: __________________________________________________________________________ _____
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Application for Student Emergency Funds

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Completed 7 October 2020

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