Student Emergency Fund – Application Form – Mental Health and Wellness

Have you been previously approved for Student Emergency Funding? *The Student Emergency Fund keeps record of all applications and will be verifying information*

Yes
No

If yes, please describe the reason for the previous Student Emergency Funding request.

Personal Identifying Information

Name*

First Last

Carleton Student ID*

Carleton Email Address*

Enter Email Confirm Email

Please note: Entering a non-Carleton Cmail account will prohibit you from submitting this form.

Study Level*

Undergraduate
Graduate
Special

Study Type*

Domestic
Exchange
International

Do you live on or off campus?*

I live in residence
I live off-campus

Criteria & Eligibility

Please check all boxes that DO apply to your situation:*

Unexpected situations such as fire, flood, theft
Domestic violence/abuse
Unexpected homelessness
Unexpected prescription medication not covered by CUSA or GSA health benefits
Temporary food insecurity
Other (Please specify in question 3)

Please check all boxes that DO NOT apply to your situation:*

Travel
Technology
Debts
Anticipated future hardship
Rent
Costs related to being an academic student
Student fees/tuition
Job loss or ongoing financial hardship

Are you a member of any of the following groups? You may be eligible for alternative emergency funding. Please select all that apply.

CUPE 4600 (TA/RA)
Enriched Support Program (ESP)
First Nations (Status or Non-Status), Métis, or Inuk
N/A

Application Questions

1. Are you a parent or guardian with dependents?*

Yes
No

2. Who is your insurance provider?*

3. Please provide a detailed description of your current, unexpected situation:*

4. Please outline your monthly expenses and budget below:*

5. Please identify other supports (if any) that you may require at this time such as mental health resources, academic support, etc.*

Consent

I confirm that the information on this form is true and I understand that I may be required to present receipts or other supporting documentation to receive funding.

The information in this message, including all attachments, is privileged and may contain confidential information intended only for the person(s) named above. Any other distribution, copying or disclosure is strictly prohibited. If you are not the intended recipient or have received this message in error, please notify Carleton University immediately by reply email at the contact listed above and permanently delete the original transmission from us, including any attachments, without making a copy. Carleton University is fully compliant with the Freedom of Information and Protection of Privacy Act and appreciates your cooperation in this matter.

Mental Health and Wellness

Student Emergency Fund – Application Form

Application and Review Process

Apply for SEF