Student Relief Fund Application
Please only submit one application
. Only one submission per applicant will be considered. For more information on eligibility, visit the
website
(linked).
Personal Information
First Name
Last Name
EMPLID
Personal Email/Best Email to Contact You
Advisor
Statement of Need
Have yo
u received an emergency grant from the CUNY SPH Student Emergency Fund before?
Yes
No
When did you receive the grant? If you received a grant from the Fund in the past year, you will not be eligible for an award.
Please select...
Within the last year
Within the last 2 years
More than 2 years ago
Are you enrolled in courses at CUNY SPH this semester? Only SPH graduate students are eligible for an award.
Yes
No
Which best describes the type of emergency you are experiencing? [select all that apply]
Medical expenses
Housing related (e.g., rent, eviction)
Food insecurity
Transportation issues
Family emergency
Natural disaster
Other
Is this financial emergency chronic (ongoing for 3 or more months) or a one-time emergency?
Chronic hardship
One-time emergency
Describe the nature of the financial emergency you are facing:
Please provide more details describing the timeline of the financial emergency:
Have you taken other steps in an attempt to manage the financial emergency via applying for external aid, budgeting and personal finances, or other methods?
Yes
No
Please describe the steps you have taken:
What prevents you from addressing the financial emergency?
Have you requested funds from other sources?
Yes
No
Please describe what other sources you have explored:
Why have you not explored other funding sources?
How has the financial emergency impacted your studies?
Is this a future or past (already incurred) expense? Future expenses will not be funded.
Future
Past
Are you able to provide documentation to support your statement of need? (e.g., termination letter, layoff notices as proof of loss of income, overdue utility bills, medical bills not covered by insurance, eviction notices, past due rent, proof of damage to property, police reports, etc.)
If you cannot provide supporting documentation, it will delay the review of your request
.
Yes
No
Expenses Breakdown
How many different financial items are you requesting for?
Please select...
1
2
3
4
5
Item 1
Item 1 Type
Please select...
Food
Housing
Medical
Technology
Natural Disaster
Other
Short Description 1
Requested Amount 1
$
Item 2
Item 2 Type
Please select...
Food
Housing
Medical
Technology
Natural Disaster
Other
Short Description 2
Requested Amount 2
$
Item 3
Item 3 Type
Please select...
Food
Housing
Medical
Technology
Natural Disaster
Other
Short Description 3
Requested Amount 3
$
Item 4
Item 4 Type
Please select...
Food
Housing
Medical
Technology
Natural Disaster
Other
Short Description 4
Requested Amount 4
$
Item 5
Item 5 Type
Please select...
Food
Housing
Medical
Technology
Natural Disaster
Other
Short Description 5
Requested Amount 5
$
TOTAL AMOUNT REQUESTED:
$
File Uploads
(If you have more than three documents, please merge additional documents into one of the three .pdf files.)
Document 1 Name
Documentation 1 to support request (i.e. evidence of unemployment, rent arrears, expenses, natural disasters, medical documentation)
Document 2 Name
Documentation 2 to support request (i.e. evidence of unemployment, rent arrears, expenses, natural disasters,
medical documentation
)
Document 3 Name
Documentation 3 to support request (i.e. evidence of unemployment, rent arrears, expenses, natural disasters,
medical documentation
)
Please take this anonymous survey for institutional record keeping. It will open in a new tab and take two minutes (
linked
).
Once completed, please return to this page and click "submit" in order to complete your application.
Contact Information