Lawson State Emergency Grant Application - workflow

Lawson State Community College

EMERGENCY GRANT APPLICATION

Please fill out all the required fields and update documentation.

Name*

First Name

Last Name

Date of Birth (MM/DD/YYYY)*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Personal Email Address*

Home/Work Phone*

Cell Phone*

School Information

Student ID# (A-Number)*

Current School*

Request Date for Funds:*

Requested Amount:* $

This is the total amount needed for assistance.

Upload Documentation #1*

No File Chosen

File uploads may not work on some mobile devices.

Upload Documentation #2, if needed

No File Chosen

File uploads may not work on some mobile devices.

Additional General Information

The information requested in this section will not be considered in the evaluation of your application.

Gender:*

Male Female

Marital Status:*

Divorced Living with domestic partner Married Separated Single Widowed

Number of dependents:*

Ethnicity:*

Hispanic or Latino Not Hispanic or Latino

Race (Mark one or more races to indicate what you consider yourself to be):*

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

English as a second language:*

Yes No

Did either of your parents complete an associate's degree or higher?*

Yes No

Are you a Veteran?*

Yes No

Are you a Foster Child:*

Yes No

Student Acknowledgement

By submitting this emergency grant request, I acknowledge and give consent for data to be shared with the Department of Education and Trellis Company, or their representatives, as part of Project Success. I understand that my information will not be sold for any purpose and will not be distributed to other parties. Examples of data shared include, but are not limited to: student name and ID, enrollment status, annual income, EFC, emergency request amount, emergency request type, etc.

Student Name (Type your Legal Full Name Here):*

First Name

Last Name

Student Signature:*

[clear]

Use your mouse or finger to draw your signature above

Today's Date:*

--- FOR SCHOOL USE ONLY ---

Approved/Denied

Approved Denied

Award decision date:

Fully paid date:

Directed to services (Specify)

Term and Year:

Category of Aid*:

Utilities Rent/Housing Medical/Dental Vehicle Expenses Gas Public Transportation Pass Childcare Food Other

Total requested amount: $

Total amount awarded:

Total denied:

Total paid:

Re-enrollment data:

enrolled graduated transferred not enrolled