Nellie Student Support Fund Request Form

Name Name * First Middle Last
Student ID *
Date Date * / MM / DD YYYY
Home Address Home Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone * - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Email Address *
What is the nature of this request? *

What is the nature of this request? Medications/Medical Care Unanticipated Academic Expense Safety Needs Replacement of Essential Belongings (related to fire, theft, or natural disaster) Travel Costs (Related to death/illness in immediate family) Rent/Utilities/Food/Essential Household Expenses Other (Please specify) Other (Please specify)
Additional Information

Please fill out all applicable sections.
Are you currently receiving financial aid or scholarships through JU? *

Are you currently receiving financial aid or scholarships through JU? Yes No
If yes, please indicate what type of aid/scholarship and the amount
Amount of funds requested (funds distributed do not generally exceed $500.00) *
Have you received funds from the Nellie Student Support Fund previously? *

Have you received funds from the Nellie Student Support Fund previously? Yes No
Please explain in detail the reason for the request and a description for what the funds will be used. *
Please attach supporting documentation or information (bills, receipts, legal notices).

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