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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):
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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)
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