Student Emergency Assistance Form
Last Name
First Name
Student ID#
Phone Number
Program of Study
Full Time (12 or more hours)
Eligible Expenses:
Child Care, Food/Meals, Gas, Housing/Rent, Medical/Dental Expenses, Personal Automobile Expenses, Public
Transportation/Bus Pass, Utilities
To Qualify:
1. Student must be currently enrolled at Edison State Community College
2. Expenses of up to $500 will be considered
3. Student permitted to receive funds once, no repeat applications will be accepted
The Process:
1. Student must complete and sign this Student Emergency Assistance Fund Application
2. The Dean of Student Affairs will review the application, request any required documentation and determine
approval or denial
3. If approved, the Dean will work with the Administration and Finance Department to make payment directly
to the vendor the student has indicated is in need of payment. The application will remain on file with the
Administration and Finance Department and Dean of Student Affairs
4. If denied, the application will remain in the student’s records and registration file
Are you receiving Financial Aid?
Number of Dependents:
Ages of Dependents:
Do you work Full Time?
Do you work Part Time?
Please attach a detailed description of the emergency/unforeseen circumstance that may prevent you from
continuing your education at Edison State and how this monetary gift could help you to maintain your schedule of
classes. (500 words or less)
Send electronically to the Dean of Student Affairs, Dr. Jessica Chambers at or drop
in-person at the Student Affairs offices at the Piqua or Darke County campuses.