Emergency Hardship Fund Grant Application

IMPORTANT: Before completing application, please review and understand all provisions, eligibility requirements, and processes of the Emergency Hardship Fund by reading http://www.src.edu/foundation/Pages/Emergency-Hardship-Fund.aspx.

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 *

Email Address *

SRC Email Address *

Total SRC Credits Completed: *

Credit Hours This Semester: *

Program of Study *

I am classified as a... *

Freshman (0-29 hours)

Sophomore (30+ hours)

I received a SRC scholarship in the previous year *

Yes

I have submitted the FAFSA *

Yes

Degree/Certificate Sought: *

I am a TRIO student: *

Yes

If you have already applied for the TRIO-SSS Grant Aid, please explain the status of that application. *

Section 2: Application Questions

1) Amount Requested from SRC Foundation (Maximum request is $500 unless applicant has express, written consent from the Dean of Students) *

2) Please describe your emergency/catastrophic event or the situation that has caused you to seek funds from the SRC Foundation. You are encouraged to justify the amount you're requesting as it relates to your circumstances. *

3) How does your situation interfere with your ability to attend SRC and/or complete your coursework? *

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

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

6) Please include/attach copies of any and all supporting documentation that provides evidence of your situation and justifies your request. Examples could include, but are not limited to: Medical Bills; Certification of Medical Condition; Insurance Claims; Police Report; Expense Receipts; Income/Expense Spreadsheet; Proof of: Unemployment, Income Loss, Job Loss, Work Closure, Foreclosure, Eviction, etc.; or anything that you believe justifies your request or provides evidence of your need.

Affirmation *

I have read and understand all criteria and requirements regarding Spoon River College Foundation’s EHF and EHF grant and SRC Foundation Scholarships, and 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 the SRC Foundation to award me with a financial grant. I hereby authorize the appropriate individuals to review my student records and disseminate information to the EHF Committee by e-mail as necessary. 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 (including, but not limited to: the Dean of Student Services, the Director of Business Services, the Director of Financial Aid, the Foundation Director, and members of the Spoon River College Foundation Board of Directors.) 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 *