2022-2023 Emergency Aid Program Request Form

Emergency Aid Request Form

Emergency aid is distributed in the form of Walmart gift cards. Completion of this request form does not guarantee you will receive a Walmart Gift card. Requests are reviewed as they are received. We try to evaluate each request as quickly as possible.
Eligibility Criteria

The needs addressed by this fund are usually urgent, non-recurring, and involve relatively small costs. Emergency funds will be provided through Walmart gift cards. These can include various scenarios, including household supplies, food items, basic necessities, automotive needs, prescriptions, etc.
- Experienced an "unexpected" emergency in the past 30 days
- Be enrolled in at least 6 hours or in a Workforce/CE program listed below during the semester when the funding is being requested.
  - dental assistant, phlebotomy, truck driving, CNA, EKG technician, pharmacy technician, medication aide, professional truck driving (CDL)
- Can demonstrate a current, non-recurring emergency need
- GPA will be evaluated on a case-by-case basis
- Summer applicants must have been enrolled in the previous spring semester or currently enrolled in a closed program (i.e., vocational nursing, OTA)
If additional information is requested, it must be provided within 24 hours, or you will need to reapply.

If you are awarded, cards must be picked up within 3 business days.
Panola College Student ID#*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How did you hear about this program? (select all that apply)*

My instructorAnother Panola studentFriend or family memberAdvisorFound on my ownFound on Panola websiteSaw it on a sign/flyerRead about it in an emailPanola College employee (other than instructor/advisor)Other
Name of Panola College employee
Are you currently enrolled in a Workforce/Continuing Education program (dental assistant, phlebotomy, truck driving, CNA, EKG tech, pharmacy Technician, medication aide, truck driving)?*

YesNo
Type of Emergency Need: (choose all that apply)*

TransportationGasMedicalClothingGroceriesTechnologyOther
What situation caused your emergency need? When did it occur? How could a Walmart gift card help you meet the needs this emergency has created? Please include estimated costs. *
If you would like to provide any supporting documents, please upload those here. Providing supporting documents may speed up the review process. If additional information is requested, you will have 24 hours to provide the information or you may be asked to reapply.

*We reserve the right to request additional documentation to verify your unexpected emergency.
Cancelof
If your application is approved, at which Panola College location would you be able to pick up your gift card(s) (select all that apply):*

CarthageMarshallShelby College Center (SCC)Shelby Regional Training Center (SRTC)
Beyond the Emergency Aid Program

Panola College has several academic, financial, and health and wellness resources available for our students.

The Feed The Need comfort closet is one of these resources offering free food and hygiene items to students. You may visit the comfort closet at any Panola College location or fill out the form here to request a bag of items.

To see a full list of student resources visit panola.edu/resources.

Confidentiality Statement:

All information submitted through this application will be held in confidence within the Emergency Aid Response Team and remain confidential according to FERPA guidelines.
Should be Empty:

Emergency Aid Request Form

Beyond the Emergency Aid Program