University of Mary Hope Grant Referral Form (To be Completed by Faculty/Staff)

Funds for Student Financial Emergencies

BEFORE YOU BEGIN: If this is an emergency that involves an immediate risk of harm to self or others, please contact Campus Safety and Security by calling 701-355-8000 from any hardline or cell phone. You also may call 8000 from any campus phone. For any emergency where police, the fire department, or an ambulance is needed call 911.

This form should only be completed by a University of Mary faculty or staff member who is referring a student for assistance with applying for Hope Grant Funds. Students needing assistance with Hope Funds should complete the online eligibility form or contact the Student Success Center (701-355-8264): https://fs16.formsite.com/assesswow/gsot019osu/index.html

In order to be eligible for Hope Grant funds, a student must:

1. Be an undergraduate

2. Be attending class at UMary's main campus

3. Be registered for classes during the term when the hardship occurred

4. Have an expected family contribution of $12,000 or less as determined by completing a free application for federal student aid (FAFSA)

5. Not have previously received Dash or Hope Grant funds through UMary

6. Be applying for a qualifying emergency.

The following expenses are eligible and are considered a qualifying emergency: Child care, food/meals, gas, housing/rent, medical/dental/vision expenses, personal automobile expenses, public transportation, and utilities. Hardships that do not fit into one of these categories still may be eligible for Hope Grant funds subject to a review by the UMary Hope Grant Committee.

The following expenses are ineligible and will disqualify applicants: parking, fines, tuition, textbooks, required tools/equipment/supplies for your program of study, entertainment expenses, and alcohol/tobacco

Student's Name: *

Student's UMary email address (if known):

Student's ID (if known):

Please select the student's current level: *

Undergraduate

Graduate

Unknown

Phone number where the student is best reached (if known):

Please select the reason the student is in need of Hope Grant funds: *

Briefly describe the need for funds: *

Your name: *

Your email: *

Your title/department: *

Explain how you learned of the student's need: *

May we share your name with the student as an initiator of the referral? *

Yes

No