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First Name:

Last Name:

Local Mailing Address:

Phone Number:

Umaryland Email Address:

Expected Year of Graduation:

Are you currently employed?

If you are currently employed, please list your employer and the number of hours you work. If you are not employed, then please write N/A.

What waivers, scholarships, loans, grants, etc. are you receiving this year?

If you are requesting emergency funds, please enter the amount you are requesting (not exceeding $500):

Describe the nature of your crisis/emergency request/situation in detail:

Explain the impact of this unexpected financial hardship on your ability to be academically successful:

Have you discussed these concerns with a University representative (Ex: faculty, advisor, Dean)?

What other community resources have you contacted?

Please attach applicable supporting documentation or information (bills, receipts, legal notices) as a PDF

Please use this space to upload more documents, if necessary:

How did you become aware of the Student Emergency Fund?

If you affirm all the above statements concerning a request for emergency funding to be accurate, please sign your name below

Sign Here

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