Big West Conference
NCAA SPECIAL ASSISTANCE FUND
Application Form

Institution			Date		

Student-Athlete			Social Security #		

Sport			Male			Female			Foreign Student Yes		 	No		

Full Grant-in-aid Yes		 	No			Partial Grant-in-aid Yes		 	No		

Pell Grant Student Yes		 	No			

Amount Requested 	$		Amount of Unmet Need	$	

Purpose for which funds are requested (check one or more).  If application is for more than one category, list the amount of money for each.

		Cost of clothing and other essential expenses (not entertainment up to $500 for Pell-eligible student-athletes and full grant-in-aid and partial grant-in-aid student-athletes who demonstrate financial need.

		Cost of expendable academic course supplies (e.g. notebook and pens) and rental of non expendable supplies (e.g. computer equipment and cameras) that are required for all students enrolled in the course.

		Medical and dental costs not covered by another insurance program (e.g. premiums for optional medical insurance, hearing aids, vision therapy and off-campus psychological counseling).

		Cost associated with student-athlete or family emergencies.

Comments:		

		
Student-Athlete’s Signature

Director of Athletics/Senior Woman Administrator’s Signature

Return Application to the Big West Conference.