Request for Student Emergency Funds
Full Name
City State Zip
Anticipated Grad Date Date of Request
Amount Requested
Place a check next to any items with which you need emergency assistance
Personal effects (clothing, shoes, toiletries)
General household (bedding, furniture, dishes, utensils)
Textbooks and school supplies (books, class materials, paper)
Food and basic necessities
Bills (electric, telephone, medical)
Travel costs related to a sudden death or illness in the immediate family
Temporary housing needs, such as rent, utilities or other essential household expense
Describe in detail the emergency event or situation (Attach additional pages if needed).
What would funding be used for? Please include an itemized description with prices, amounts, payment due
dates and other pertinent information. (Attach additional pages and documentation if needed).
Is this request for a reimbursement of funds already spent?
If yes, please attach receipts No
Please list and include amounts of all internal/external scholarships, grants and loans
Have you received monies from the Emergency fund before?
Yes No
If yes, when and how
Are you currently
Yes No
If yes, how many
If no, list reasons for not having or seeking employment
Please list all employers
Please list all campus and/or community involvements and other time commitments
Please provide any other information that you feel the committee should know (Attach additional pages if
I certify that by checking the accept box that the answers given herin on this application are true and complete. I
give permission for committee members to speak with necessary WNCC departments to verify the information
provided and I understand I may be asked to meet with the committee as necessary. I also understand that any
fraud or intentional deception on my part can lead to disqualification. I acknowledge that I will b held responsible for
reimbursing funds if awarded should there be evidence that my statements are not true and complete.
I accept these terms Current Date
Submit this form to the Western Nebraska Community College Foundation, 2620 College Blvd, Scottsbluff, NE 69361. Please
contact us at 308-630-6550 or at if you have questions.
Application Approved Amount Awarded
Date Approved Date Notified
Date Check Picked Up Check Number