Student Emergency Fund Application

Background Information

First and Last Name

Select Gender

UTCID

Phone number

Email address

Questions & Agreement

Please provide a detailed summary of the reason for your request and how the situation is of an urgent or emergency nature (e.g., Accident, Emergency, Illness, Other Unforeseen Event).(Required) This field is required.

What is the total amount of funding you are requesting?(Required) This field is required.

Please provided a list of the expenses and the total amount of each expense.(Required) This field is required.

How will funding, if awarded, be used to alleviate the financial concern?(Required) This field is required.

If the requested funding is for a recurring expense (e.g., utility bill), what is your action plan to ensure you can make future payments after the urgency or emergency is resolved? This field is required.

If you are not awarded funding, how will this financial concern impact your ability to continue your education at UTC?(Required) This field is required.

Please provide a summary of any attempts you have already made to find other sources of funding prior to making this request, if any.(Required) This field is required.

Is the requested funding for rent or mortgage payments in which you have been warned or received notice that you will be evicted? [If yes, please attach a copy of any notice to your supporting documentation](Required) This field is required.

Are you currently receiving any financial aid (e.g., Scholarships, Loans, or Grants)?(Required) This field is required.

Are you eligible for any financial aid (e.g., Scholarships, Loans, Grants) that you have not accepted?(Required) This field is required.

Do you currently have an outstanding balance with the University (Bursar's Office)?(Required) This field is required.

Have you used the Student Emergency Fund previously?(Required) This field is required.

Are you currently employed?(Required) This field is required.

Are you experiencing any food insecurity or other basic needs concerns?(Required) This field is required.

Acknowledgement: By signing this form, I attest that I am a current (or continuing) University of Tennessee at Chattanooga (UTC) student. I am enrolled in the current semester as a part-time, half-time, or full-time student (or have pre-registered if between semesters). All of the information provided in this request is true and accurate to the best of my knowledge. I understand that falsifying or withholding information in this application is a violation of the Student Code of Conduct. If awarded funding I understand that (1) I will be required to develop a plan for future financial stability in conjunction with the UTC Financial Wellness Center and (2) I agree that the University of Tennessee at Chattanooga (UTC) may share non-personally identifiable information with individuals (donors) who provide monetary support for the Student Emergency Fund. Electronically sign by typing your full name below(Required) This field is required.

Indemnification and Hold Harmless Agreement: I, the undersigned, in consideration of the permission and privilege allowed me hereunder, do hereby specifically agree that I will indemnify, save, and hold harmless all administrators, volunteers, donors, The University of Tennessee and all its part-time and full-time employees, representatives, officers, and trustees from any and all losses, claims, actions, or proceedings of every kind and character which may be presented or initiated to recover money, property, or damages, for any injuries to persons, or injurious results by use or receipt of funds from the "Student Emergency Fund". In accepting, I understand that this agreement extends and applies to any personal injuries, injurious results, damages, or losses which I, myself, may experience or sustain directly or indirectly. I covenant for myself, my estate, executor, heirs and assigns, not to file suit or initiate any claim procedures in respect to any personal injuries, property damages, or losses I may experience or sustain by use or receipt hereunder. I freely assume all risks, hazards, and losses which shall apply to use or receipt of funds from the "Student Emergency Fund". Electronically sign by typing your full name below(Required) This field is required.

Supporting Documentation

Please attach any documentation supporting your request. For Student Emergency Fund requests, documentation may include items such as rent/lease agreement, utilities bill, car payment bill, insurance bill, cell phone bill, or other expenses in your name must be attached. Requests without appropriate documentation may be automatically denied. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission