Atlantic Coast Conference



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Atlantic Coast Conference


NCAA SPECIAL ASSISTANCE FUND

ACC Application Form




Student-Athlete:      

Male

Female

Institution: Georgia Tech

Sport:      

Other Institutional ID#      

SSN:      







1. Is the Student-Athlete a Foreign Student?

Yes No

2. Is the Student-Athlete a Pell Grant Recipient?

Yes No

3. Is the Student-Athlete an Athletics Grant-in-Aid Recipient?

Yes No

If yes, Full Grant Partial Grant




(Please complete one section below)







SECTION 1 – PELL GRANT RECIPIENT




SECTION 2 – NOT A PELL GRANT RECIPIENT
















PURPOSE (Check one):

Medical or Dental Expenses not covered

by another insurance policy.
Costs Associated with Student-Athlete or

Family Emergencies


Purchase of Expendable Academic

Course Supplies


Rental of Non-expendable Course

Supplies Required for All Students

Enrolled in the Course
Clothing and Essential Expenses

($500 limit)






Amount Requested: $ 250.00 Per a semester

Student-Athlete Date

Athletics Directors /SWA Designee Date

Financial Aid Representative Date

ADDITIONAL SIGNATURE FOR FOREIGN S-A:



Foreign Student-Athlete Advisory Date

Entity or Financial Aid Representative
MAKE CHECK PAYABLE TO:
     


PLEASE SEND CHECK TO (Name and Address):
     


     

     





















Part 1: CRITERIA CHECKLIST

(All steps are necessary for eligibility)
Student-Athlete receives athletically related

financial aid


For domestic student-athletes. As certified

By the Financial Aid representative’s signature

below, the student-athlete has demonstrated

financial need as determined by an analysis

conducted consistent with federal methodology

or the methodology used for all students at the

institution.

OR

For foreign student-athletes. As certified by

the foreign student-athlete advisory entity

representative’s signature below, the foreign

student-athlete has financial need.


Part 2: PURPOSE (Check one):
Medical or Dental Expenses not covered by

Another insurance policy.


Note: Optional medical insurance premiums are

permissible
Costs Associated with Student-Athlete or Family

Emergencies


Purchase of Expendable Academic Course Supplies
Rental of Non-expendable Course Supplies

Required for All Students Enrolled in the Course


Clothing and Essential Expenses for student-

Athletes receiving an athletics grant-in-aid

(partial or full) ONLY ($500 Annual Limit)



Updated 6/23/05

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