University School of Medicine Student Emergency Fund

Instructions: This form is for School of Medicine M.D. degree students at the University of Louisville who encounter an unforeseen financial emergency or catastrophic event and require financial assistance. Please read the criteria carefully and provide all necessary information.

Acknowledgement:

The funds from this application are not intended for routine expenses (such as monthly bills, routine maintenance costs, board exams or board preparation).
This application does not guarantee approval of the requested funds.
Receiving funding may impact financial aid packages.
If approved, funds will be awarded to the student's University account for disbursement.

The decision for awards from the School of Medicine Student Emergency Endowed Fund will be determined by the Associate Dean of Student Affairs of the School of Medicine, in consultation with the SOM Emergency Fund Committee.

Full Name

Student ID

Email Address

Phone Number

Description of the Emergency/Catastrophic Event: (Provide a detailed account of the situation and why you are in need of the emergency fund. In order to meet the criteria for Emergency Funds, an event or unforeseeable circumstance must have occurred.)

Please explain how the funds will be used.

Please explain the impact of these unexpected expenses on your ability to remain enrolled at UofL. Note: Priority will be given to students whose enrollment may be at risk as a result of these expenses.

Please describe efforts, if any, made to secure funds (in addition to this application).

Attach applicable supporting documentation Attach applicable supporting documentation or information (utility bills, receipts, legal notices, rental/leasing agreements, medical bills/co-pays, etc.). Documentation needs to include identifying information (i.e. name, address, etc.) of the applicant.

Current Financial Aid Status:

Receiving Financial AidNote Receiving Financial Aid

Amount requested from the fund $

Any unpaid balances on the University Account $

Are you a single parent with a dependent child?

YesNo

Have you received assistance from the Emergency Fund previously?

YesNo

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