Emergency Fund Application

Student's Full Name*Enter Your Full Name

Complete Mailing Address (current, include house or apt #, street, city, state, zip*Enter Your Full Mailing Address

Preferred Email Address*Enter Your Email Address

Current Phone Number*Enter Your Phone Number

Which campus to you attend?

Malone Campus

Saranac Lake Campus

Ticonderoga Campus

Online

Extension site

Select the campus location you attend most of your classes

Are you employed?

Employed full-time

Employed part-time

Currently unemployed

Select your employment status

If unemployed, please let us know the circumstances of your unemployment.Please select the best fit

Number of Dependents*Please select one

Category of DependentsPlease select all that apply. To select more than one hold the Ctrl button as you select.

Please select the reason(s) you need this emergency funding support:

Utilities

Rent/Housing

Food/Meals

Personal Hygiene Items

Transportation/Auto Expenses (gas, repairs, auto payment)

Childcare Expenses

Medical Expenses (physician, dental, eye, mental health, etc),

Select All That Apply

Please explain your needs in greater detail so the review committee has a better understanding of your most immediate needs. Please note, copies of a budget plan or invoices may be required to complete the review of your request.*Describe Your Request In Detail

Enter the amount of your request for emergency financial assistance:*Our funding capacity is limited currently. Requests over $50 may take longer to approve. Maximum amount you may request is $500.

Your Monthly BudgetPlease itemize your typical budget including monthly bills with amounts

If requesting grocery or gas assistance, please select what type of gift card would be most preferable to you. (Available in $50 increments)

Hannaford

Pricechopper

Tops

Wal-Mart

Gas Station (various)

Select Type of Gift Card (if applicable)

I understand that I am eligible for each type of emergency funding only once while in attendance at North Country Community College. Once approved, I will NO longer be eligible for the same emergency fund request. If approved for a Ragusa Loan, I understand that if for any reason the approved financial aid funds are insufficient to cover tuition, fees, books, and this emergency loan, I am fully liable for repayment. (Note, for students who fail to repay the Ragusa Loan, a “HOLD” will be placed on all records at North Country Community College. Loans not collected will be turned over to a collection agency and applicants will be liable for the cost of collection in addition to the unpaid balance and lose eligibility for all other emergency funding sources at the college.)*Enter Your Student ID Number to Sign Your Application