Emergency Fund Request Version 15.0

Joyce Roberta “JR” Miller-Alper Emergency Fund for Adjunct Faculty

Request

Request Date:

Emplid

*HR Employee ID:

*Estimated Household Income:

*Emergency Situation:

Car Repair

Transportation Difficulties

Broken Appliances / Repairs

Pet Care

Cost of caring for immediate family member

Technology Issues not covered by the Tech Toolkit

Others - specify:

Specification for Other

Required if "Others" is checked.

More Detailed Information: (max. 1000 characters)

*Amount Requested:

Selection

*Have you applied to this fund before?

Yes - PT Faculty

No

Yes

No

If so, when did you make the request?

When the previous request was made

Required if Yes is selected.

*How the funds will help? (max. 1000 characters)

HCC emailSelectionStage Role DisplayInstance Number Display

*Job Title as Part-Time Faculty?

*Last employment at HCC:

Selection

Term:

Academic Year:

Year

ex. 2020

Loading