Fillable REQUEST FOR STUDENT EMERGENCY FUND APPLICATION (Cisco College)

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REQUEST FOR STUDENT EMERGENCY FUND APPLICATION (Cisco College)

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REQUEST FOR STUDENT EMERGENCY FUND APPLICATION
Eligibility:
- I have completed at least 12 credits at Cisco College.
- I am registered for at least 6 credits for the semester in
which I am requesting assistance.
- I have a 2.0 GPA or more and 50% completion rate at CC.
(If you answered “yes” to all of the above you are eligible to apply.
Student Information: (please print)
Name: ID #
Address: City State Zip
Phone (Home) (Work) (Cell)
Email Address
Briefly describe your financial emergency or catastrophic event and how this fund will help alleviate your
circumstances by assisting you with your tuition, fees, and books for this semester or the following se-
mester. (Attach an extra page if needed)
______ Yes ______ No
______ Yes ______ No
______ Yes ______ No
REQUEST FOR STUDENT EMERGENCY FUND APPLICATION CONTINUED
Are you currently employed?
Marital status:
Number of Dependents in your household
______ Yes ______ No ______ Full ______ Part-time
______ Yes ______ No Date_________
______ Yes ______ No Date_________
______ Yes ______ No Date_________
______ Yes ______ No Date_________
Estimated expenses per month. Please list: rent; food; gas; utilities; childcare; etc.
Total Expenses per Month $
Estimated Income (per month - list all resources) employment; spouse; parents
Total Income per Month $
Comments from a Cisco College Faculty, Couselor, or Staff member if available: attach or if you prefer
send via-email to: martha.montgomery@cisco.edu
Committee approval or disapproval:
Martha Montgomery
Amy Callan
Dr. Kathie Wright
Diane Carlile
Request approved for
Request Denied
______ Funds not available
______ Incomplete application
______ Request not unforeseen or
“catastrophic” in nature
______ Other
Student notified Date
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REQUEST FOR STUDENT EMERGENCY FUND APPLICATION (Cisco College)

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Completed 27 July 2020

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