First name*

Last name*

Today's date*

Program of study*

Street address*

City*

State*

Zip code*

Email*

Phone*

Previous Funding

Have you received COA Cares funding before?*
YesNo

If yes, which semester?
SpringSummerFall

What year?

Have you applied for scholarships and/or financial aid? If not, visit our Costs and Paying for College page or email coafainfo@albemarle.edu for assistance (Note: this is not required for COA Cares, but may be necessary for additional types of aid).*
YesNo

Need

Please select the category of your need:*
Auto repairsBooks and school suppliesChild/dependent careHousing/rentInternetMedical/dental/vision careTransportationTuition and feesUtilitiesOther

Ineligible requests: mortgage payments, car payments and cable bills

COA Cares was established to assist individuals with unforeseen emergency situations that could interfere with a student's ability to complete his/her education/training.

Provide details about your emergency and how this emergency has impacted your ability to continue with your course(s). For example, you might explain how a recent job loss impacts your ability to pay for your month's rent. Please be as detailed as possible.*

Amount requested (up to $250)*

You'll be asked to submit documentation/proof of your financial emergency upon submission of this application. A representative from COA will request this once the application is received. For example, if you're requesting utilities assistance, an overdue notice is an example of documentation. If you're requesting assistance with a rental payment, a copy of your lease agreement is an example of documentation. If you're requesting transportation/gas assistance, a copy of your course schedule is an example of documentation. Students are encouraged to have this information ready so that their emergency situation can be dealt with in the quickest manner possible.

I attest that the funding being requested through COA Cares isn't being covered by another source (ex: Department of Social Services) and that the unforeseen expense won't be a chronic financial problem as the COA Cares Funds aren't to be used as a consistent source of remedial funding.*