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Golden LEAF COVID-19 Scholarship Fund
Student Application
North Carolina Community Colleges and Golden LEAF want to aid students directly or indirectly impacted
by the Coronavirus Outbreak and the move to on-line instruction in the Spring 2020 term. Please
complete the application to request assistance with expenses related to COVID-19 (i.e., childcare, living
expenses, internet access, computer). Eligible students must reside in a rural county that is tobacco
dependent, or economically distressed, as determined by the Golden LEAF Foundation. Please see your
school’s financial aid office for a list of 2019-2020 Qualifying Counties.
Instructions: Complete this application and return the completed application to the college’s Financial
Aid Office.
Section One: Personal Information:
Full Name: _________________________________________________________________________
Social Security Number/Student ID Number:_______________________________________________
Home Address: ______________________________________________________________________
City, State, Zip Code: __________________________________________________________________
E-Mail Address: ______________________________________________________________________
Phone/Mobile Number: ____________________ County of residence: _________________________
Length of residence in county: ____ less than 5 years ____ 5 10 years ____ more than 10 years
Section Two: Educational Information:
____ Occupational Continuing Education Student (must be enrolled in a credentialing program of at least
96 hours.)
Program of Study: _____________________________________________________
____ Curriculum Student:
Program you are enrolled in: _____________________________________________________
Section Three: Reason for Applying:
Please indicate the reason you are applying for Golden LEAF COVID-19 Scholarship Fund.
Please describe how the Coronavirus has affected you and led to your need for assistance from the
Golden LEAF COVID-19 Scholarship Fund:
_____ Student need to purchase laptop, headset for computer or other supplies to assist you in logging in
to complete your courses.
_____ Student short term or long-term loss of employment
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_____ Student has needs assistance with food or other basic needs
_____ Student needs assistance managing COVID related responsibilities at home (lack of a dedicated
computer, need to care for children/siblings/ill family members, etc.)
_____ Student needs assistance with childcare and health care.
Other: Please
I have read and understand the requirements for assistance. I hereby declare that the information
provided on this form is complete and correct to the best of my knowledge.
_______________________________________ ____________
Applicant’s Signature Date
Please return the completed application to the college’s Financial Aid Office.