Health Careers Program
Fee Assistance Application
This application is for assistance with parking and other unforeseen course/clinical expenses. Funding may be provided in full or in part at the discretion of MCC Foundation
towards unpaid balances only. Reimbursement for expenses paid out-of-pocket or covered by other funding sources will not be considered. This application does not cover
outstanding tuition balances. Students in need of tuition assistance must fill out a Foundation Scholarship Application by going to manchestercc.edu/scholarships.
Complete this application, sign, date, attach a copy of your current semester billing statement (obtained from the Bursar’s office), have authorized personnel from Financial Aid
or Bursar’s office sign this application confirming your need for financial assistance, and return completed application to Student Services Center, L231. Incomplete applications
will not be considered. Questions, call 860-512-2909 or email dreid@manchestercc.edu.
PROGRAM
Program of study.
n
Dental
n
Health and Exercise Science
n
Radiation Therapy
n
Radiography
n
Respiratory Care
n
Occupational Therapy
n
Surgical Technology
Please select assistance needed (outstanding tuition balances will not be considered)
n
Parking Pass; number of months needed ___________ Amount Needed __________
n
Other unforeseen course/clinical expenses (i.e. fingerprinting, background check, etc.) Please Describe ______________________________ Amount Needed _________
Briefly explain why assistance is needed
APPLICANT INFORMATION
First Name MI Last Name Banner ID
Street Address
Apt. #
City State Zip
Phone Email
Date of Birth
Gender
n
Male
n
Female
n
Prefer not to identify
Are you an international student?
n
Yes
n
No
Work status
n
Full-time
n
Part-time
n
Unemployed
n
MCC Work Study Student
ACADEMIC INFORMATION
I am attending MCC as a
n
Full-time student (12 or more credits)
n
Part-time student (less than 12 credits)
Credits earned to date Anticipated graduation date
Is this your first semester?
n
Yes
n
No Do you receive financial aid ?
n
Yes
n
No
If yes, do you receive the Pell Grant?
n
Yes
n
No
FINANCIAL AID OR BURSAR RECOMMENDATION REQUIRED
Please obtain the signature of an authorized individual from the Financial Aid or Bursar’s office who can confirm your need for financial assistance.
Signature Printed Name
Date
Email
Phone Extension
REQUIRED
I have carefully read and completed the application and, to the best of my knowledge, the above information is true and correct. I understand that this application will be kept confidential
and I give permission to Financial Aid or Bursar personnel who provided recommendation to discuss my application and financial needs with the MCC Foundation/Institutional
Advancement staff. Please note: Funds are disbursed as they become available.We regret that not all requests will be granted.
Applicant Signature Applicant Printed Name
Date
October 2018/PR
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