Application Form Student-Athlete:_____________________; Sport:_______________; Pell:_____; Athletic Aid with Unmet Need:______
Institution:_________________________; Male:________ Female: ________; *International Student:_________
Conference: Metro Atlantic Athletic Conference Purpose for which funds are requested:
1. Medical Expenses (except those covered by another insurance policy),
including optional institutional medical insurance premiums.
2. Hearing Aid ________
3. Vision Therapy ________
4. Off-Campus Psychological counseling ________
5. Costs associated with student-athlete or family emergencies ________
(Include written description of emergency)
6. Purchase of expendable course supplies (e.g. notebook and pens) ________
7. Rental of non-expendable course supplies (e.g. computer equipment and cameras ________
that are required for all students enrolled in the course.)
8. $500 Allowance ________
Transportation home from the institution __________
TOTAL AMOUNT: ________
If request includes money for clothing, shoes, or other essentials, please indicate the total amount the student-athlete has received during the current academic year: ____________________________________.
As the applicant, I verify that I am a PELL GRANT athlete who is participating on a varsity team or a student-athlete who is receiving countable athletically related financial aid and has demonstrated need as determined by the financial aid office.
Non-qualifiers may not receive special assistance funds during their first academic year in residence.
All SA’s who qualify for the fund, have access to all categories of the fund.
*For a foreign student-athlete, an official foreign student-athlete advisory entity of the institution outside the athletic department must certify in writing that the student-athlete has a financial need. Please send documentation to the conference office.
Student-Athlete Signature Date
Director of Athletics/Senior Women’s Administrator Date