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Student Name
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First Name
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Initial (optional)
Last Name
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Please provide the most recent term you completed. (i.e. Fall 2021, Spring 2019, Summer 2018, etc.)
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Student ID
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Email
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Phone
How do you intend to use these funds if received? (Check all that apply).
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Academic (tuition, fees, books)
Financial Holds (holds from a past due balance from LSC or another institution)
Childcare (babysitting, daycare)
Groceries (food, toiletries, cleaning/paper products)
Healthcare (insurance, doctor/clinic visits, medication/medical equipment, dental, vision, counseling)
Housing (rent, mortgage, utilities)
Transportation (gas, car/insurance payment, bus fare)
Technology (cell phone, laptop, tablet, internet connection)
Other
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