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Situational Accommodations
Application for Assistance Not Related to Educational Accommodations
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* Indicates required question
Email
*
Your email
Current Semester
*
Your answer
Name:
*
Your answer
Cell Phone or Home Phone:
*
Your answer
Living Address:
Your answer
Student ID Number:
*
Your answer
Gender:
Female
Male
Prefer not to say
Non-Binary
Other:
Clear selection
Race:
White (German, Irish, English, Italian, Lebanese, Egyptian, etc.)
Black or African American (African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.)
American Indian or Alaska Native (Navajo Nation, Blackfeet Tribe, Maya, Aztec, Nome Eskimo Community (etc.)
Asian (Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, Native Hawaiian, Samoan, etc.)
Prefer not to say
Other:
Marital Status
Single
Married
Separated
Divorced
Domestic Partnership
Prefer not to say
Clear selection
Academic Goals:
*
Increase Skills
Associate Degree
Certificate Program
Transfer
What major have you chosen?
Your answer
Are you part of any of the populations listed below?
*
Economically disadvantaged (financially eligible to receive financial aid)
Documented disability (support services has your documentation on file)
Single parent with children under 18
Single pregnant woman
International student
Displaced student/homemaker
In a major non-traditional for gender
English Language Learner
Of a historically marginalized community
Required
What are your biggest obstacles? (Check all that apply.)
*
Financial Needs
Housing
Transportation
Child Care
Interpersonal/Emotional Distress
Campus Climate (feelings of exclusion, hostility, not belonging, etc.)
Academic difficulties
Other:
Required
Which of those obstacles is your biggest concern at the moment?
*
Your answer
I certify that I am financially eligible for aid, and that I am in need of assistance:
*
Yes
No
Required
I understand that I can receive a maximum of two assistance cards per semester:
*
Yes
No
Required
It is my understanding that this assistance is to aid in my persistence on campus, and therefore I intend to do all I can to pass my course(s) to the best of my ability:
*
Yes
No
Entering my name on this document is proof of my signature. Lying on this form is grounds to bar me from further assistance services.
*
Your answer
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