Apply For A SMERF Grant

Jack Canfield Student Medical Emergency Relief Fund

Applicant Information:

Are you currently a registered student of UCSB?

If so, please provide their full name and their UCSB department if facutly or staff.

 

Emergency Information

What was the date of your medical emergency or emergencies? In the case of an upcoming emergency procedure, what is the scheduled date and time for your procedure?
Did emergency happen while attending school at UCSB?


Type of Emergency




Do you currently have any outstanding medical bills, quotes, cost of services, or other supporting documentation?

Please note:
The Canfield/SMERF Fund cannot process payments with insurance company Explanation of Benefits (EOB) as the back up documentation. The actual bills, quotes, cost of services or other documentation must be submitted.

There are no reimbursements for bills that have already been paid. SMERF can only pay the provider. of the service directly. Payments cannot be made directly to an applicant nor can payment be made to a creditor (ie credit card comapny).

Do you anticipate additional bills regarding this emergency?

Letter to Committee
Upload a typed letter to the committee describing the nature of your emergency including the cause, the cost, and what you have done to address the situation so far. Please include how you foresee yourself resolving this situation. Prepare and save this letter in Word or PDF format.
Medical Bills
Please scan and upload a copy of your outstanding medical bills. If you have not received treatment, upload a copy of your estimated treatment plan. If you do not have access to a scanner, submit your bills in a sealed envelop to Rec Cen Room 1110 and address it to SMERF Account Manager

Additional Information

Are you an EOP student?


Are you enrolled in UC SHIP Insurance?

Are you currently employed?


Are you a financial aid recipient?

Do you have loan eligibility? You can check on the Financial Aid website under Student Loans (https://finaid.ucsb.edu/aidstatus)

Are you interested in receiving information on other campus resources?

As university employees we are mandated to submit a report to the Title IX office regarding incidents of  sex discrimination, sexual harassment and sexual violence. If a report is submitted, the Office of Equal Opportunity & Sexual Harassment / Title IX Compliance will contact you.  Once contacted you have every right to participate or not in the investigation or Report.