CCF Emergency Assistance Form

Academic Information
Legal Name*

First NameLast Name
Student ID Number*
Please include the "@" symbol
Semester
Units in progress at Cypress*
Units Completed at Cypress*
6 unit minimum
Units completed at other institutions*
Cumulative GPA*
Major*
You've indicated you're a Nursing, Psych Tech, Rad Tech, Dental Hygiene, Medical Sonography, or Mortuary Science major, have you been officially accepted into the program?

YesNo
Who is your Counselor?
Affinity Group(s)*
e.g., EOPS, DSS, Legacy, Puente, Veteran

Contact Information & Disbursement Option
Email*
example@example.com
Cell Phone*
Address*

Street Address

CityState / Province

Postal / Zip Code
Referral - Cypress Staff/Faculty Name*
This person should be familiar with your situation.
Referral - Staff/Faculty Cypress College Email*

Confirmation EmailEnsure a valid Cypress College email is used. They will be contacted in regard to this request.
Select disbursement preference below; applies if application is approved.*

PayPalCheck by MailCheck for in-person pick up at the Foundation OfficeIf request is for fees owed to Cypress College, select this option to disburse funds directly to Cypress College (Bursar's Office)
PayPal Email Address
example@example.com
Should be Empty:

Emergency Funding Request