Pipeline for the Advancement of the Healthcare Workforce (PATH) Financial Assistance Grant Application

Section 1: Student Personal Data

Last Name *

First Name *

Middle *

SRC Student ID #: *

Date of Birth: * +

Maiden Name (if applicable):

Street Address *

City, State, Zip *

Phone Number: *

Email Address *

SRC Email Address *

Program of Study *

SRC Advisor: *

Semester *

Campus Attending *

I am classified as a... *

Freshman (0-29 hours)

Sophomore (30+ hours)

I have submitted the FAFSA *

Yes

No

Degree/Certificate Sought: *

I am a TRIO student: *

Yes

No

Section 2: Application Questions

1) Please list in detail the items that you need financial assistance with and the amount requested for each. *

2) Please provide any additional information that has caused your financial needs. *

3) What efforts have you made to obtain funding from other sources and have you been successful? *

4) Have you communicated with any SRC staff or faculty about your needs/hardship/emergency? If so, who? *

Affirmation *

I certify that all information I have supplied on this application is correct. I understand that applying does not guarantee approval, and that submitting an application does not obligate SRC to award me with a financial grant. I hereby authorize the appropriate individuals to review my student records. I understand that the information I have submitted will be handled privately and will not be shared beyond those with a distinct need to review my application. I also understand that those individuals may contact me for further information. I understand that checking this box signifies agreement with the policies outlined in this application. I also understand that, while SRC goes to great lengths to ensure that my information is secure, electronic submission of this information is at the sole risk of the applicant if I choose to submit electronically.

Type your name below, which will serve as your electronic signature *

Ready to Submit?

Yep!

Section 3: Dean of Career & Workforce Education

Comments:

Dean Decision:

Approved

Denied

Ready to Submit?

Yep!

Section 4: Allied Health Coordinator

Comments:

Coordinator Decision:

Approved

Denied

Ready to Submit?

Yep!