Student Emergency

Student Name (First, Middle Initial, Last)*

Street Address*

City*

State

Zip*

Phone*

Email*

Gender*

MPTC Student ID #*

Program(s)*

GPA

Number of credits in current semester*

1. What are your current responsibilities (check all that apply):*

Family Obligations
School
Work
Other

Please indicate the hours per week you are responsible for the above activities

Family Obligations

School

Work

Other

2. Did you apply for Financial Aid (FAFSA)?*

3. Are you currently a PELL-Grant recipient for the semester which you are requesting support?*

4. Are you currently working with any staff, faculty, Campus Counseler, or any other Student Services providers on campus?*

Please list

5. Are you working with any person(s) in community agencies off campus?*

Please list

6. What community resources have you applied for assistance with in the past year?*

7. What community resources are you currently receiving financial assistance from?*

8. What is the reason for your request (accident, illness, job loss, health, unforeseen event, etc.)?*

Be thorough in your description of your situation and how the money will be used?

9. What is the dollar amount you are requesting? (ie. 100.00)

10. Is there any other information you feel we should know to help us understand your circumstances?*

11. Identify your area(s) of needed assistance (Choose all that apply)*

Medical
Food
Dependent Care
Transportation
Rent/Housing
Utilities
Automotive
Other

If other, please list

I have read through the information, eligibility requirements and the application process.*

Yes

I agree that all information listed is accurate and correct to the best of my knowledge.*

Yes

I am including documentation regarding my need for assistance*

Yes

To submit documentation:

Email
studentemergencyfund@morainepark.edu

Fax
920-907-6974

Mail
Moraine Park Technical College
Attn: Student Emergency Funds
235 N National Ave
Fond du Lac, WI 54936

Or in person at any MPTC Campus Student Services' Main Office.

PLEASE NOTE-Applications without documentation will not be considered.

Electronic Signature*

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