Emergency Relief Application

Full Name

Student ID Number

Date of birth

Month

Day

Year

Phone

Permanent Address

Current Address (if different from permanent)

Phone Number

College/University Name

Current Academic Year (Freshman, Sophomore, Junior, Senior, Graduate)

Major/Field of Study

Expected Graduation Date

Description of Emergency: Brief explanation of the circumstances leading to the need for assistance.

Type of Assistance Needed: Tuition, Housing, Food, Transportation, Medical Expenses, Other.

Amount Requested.

Supporting Documentation: Attach any relevant documents (e.g., bills, notices, medical records)

Impact Statement: write a brief statement on how the requested funds will allow you to stay in school or meet essential needs.

I consent to POWER verifying the provided information with the university or relevant parties. Confirm with your initials.

I declare that the information provided is accurate and complete. Confirm with your initials.

I agree to the terms and conditions of the aid (e.g., funds must be used for the specified purpose). Confirm with your initials.

Optional: Names and contact information for faculty or staff who can verify your situation (if applicable)

Social