Student Equity Program Resource Referral Form
For One Semester Only
Student Name: Student S#:
Phone Number (best way to contact):
Reason for Referral:
Employee making referral: Signature:
Student Equity Notes
Office of Student Equity
(530) 938-5376
Student Equity Funds Expenditures
Student Equity Funds will be used for the following:
1. Book vouchers, gas vouchers or bus tickets and/or supplies for students who have “timed out” of EOPS,
CalWORKs and Financial Aid.
a. The above students must be referred via referral system.
b. Students must have an Education Plan on file with the Counseling Office that addresses the student’s
current student academic goal.
c. Student Equity Funds will only be used for those courses identified in the plan.
d. Books must be purchased at the COS Bookstore. The student will submit a list of books with costs
before authorization is granted for a Student Equity book voucher
e. Students must be making satisfactory academic progress toward goal. (Students must have a 2.00 grade
point average or better, have been completing at least 75% of courses each semester for previous
semesters, etc.)
f. This request/use of Student Equity funds is for one semester, and not to be considered ongoing funding,
with the exception of Siskiyou Promise book vouchers, per guidelines.
g. Student Equity funds will NOT be awarded to students who are currently receiving an EOPS book
voucher, and are not simultaneously eligible for a Siskiyou Promise book voucher.
2. Student Equity will fund eligible Siskiyou Promise book vouchers and/or supplies for four semesters, at $200
each semester. Remaining book voucher allocations for a semester may be rolled forward to the proceeding
term in the same fiscal year.
a. Eligible Siskiyou Promise recipients may request one-time bus tickets or gas vouchers and/or class-
related supplies in emergencies. These students must also be referred via referral form.
3. Students who have financial aid pending may request one-time assistance for gas vouchers or bus tickets.
4. Student Equity funds will no longer be used for Food Service meal cards. Students in need of food will be
referred to the COS food pantry.
5. Students who receive assistance via referral process will also complete a “contract,” which will state
expectations and limitations.
6. All other Student Equity funds will be expended on activities listed in the SSSP, Basic Skills and Student Equity
Integrated Plan.
7. Please allow 2 to 3 business days to process.
8. Please note that this award will count toward your financial aid as a resource.
Student Signature and Acknowledgement Date
(Revised March 5, 2018)