Student Application Form

Emergency Loan Fund

Instructions: Please complete the Application Form and the Sign-off Form (see next page). Both forms must be fully completed before they are submitted to CCRI's Office of Institutional Advancement. Incomplete forms cannot be considered for funding. Please print clearly or type.

Name_____________________________________ Student I.D. # ___________________________

Address___________________________________ City________________ State______ Zip_______

Telephone__________________________________ e-mail __________________________________

1. List current or most recent Health and Rehabilitative Science course registrations.

2. Describe the extenuating circumstances, which have developed causing you to need a *loan at
this point in time.

3. Have you ever received a loan from this fund? Yes___ No___

If yes, how much was the loan? ________

4. Expected date of graduation? _____________

5. I am requesting a loan of $________(cannot exceed $200)

6. I agree to repay this loan to the CCRI Foundation* on or before

__________________.
(Date of repayment)

I grant my permission to the Scholarship Review Committee to review my academic standing with CCRI's Office of Admissions and Records and to review my financial need with CCRI's Financial Aid Office.

______________________________________________
Student Signature/Date

*Loan repayments should be made payable to the CCRI Foundation and sent to CCRI's Office of Institutional Advancement, 1762 Louisquisset Pike, Lincoln, RI 02865-4585.