Apply For A SMERF Grant

FALL 2022 QUARTER UPDATE

At this time, the SMERF grant has exhausted its Fall quarter allocation of funding for Medical, Dental, and Optical emergencies.

Students with medical expenses and UCSHIP are encouraged to explore the Campus Medical Care Assistance Fund instead. 

Students with Mental Health related expenses can still complete a SMERF application to be considered for the Equity in Mental Health Grant.

Jack Canfield Student Medical Emergency Relief Fund

Applicant Information

Are you currently a registered student of UCSB?

 

Emergency Information

Type of Emergency




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?


What is the financial status of your medical emergency?


Do you currently have any medical bills, quotes, cost of services, or other supporting documentation relating to this medical emergency?

Letter to Committee
Please 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 and any other relevant information. Please include how you foresee yourself resolving this situation. Prepare and save this letter as a PDF document.
Supporting Documentation (Medical Bills / Estimates)
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, please submit your bills in a sealed envelop to the Office of Financial Aid and Scholarships (SAASB Building) and address it to SMERF Committee
    

Additional Information (Optional)

Are you an EOP student?


Are you enrolled in UC SHIP Insurance?

Are you interested in receiving information on other campus resources?

                                              

Release of Information

***PLEASE READ BEFORE SUBMITTING***

This authorization to receive or release medical information is being requested of you to comply with the terms of the Confidentiality of Medical Information Act of 1980, Section 56 et seq. of the California Civil Code. Release or transfer of the specific information to any person or entity not specified herein is prohibited. An additional written consent must be obtained for a proposed new use of information or for its transfer to another person or entity. Release of records obtained from a person or entity other than UCSB Student Health Services is prohibited.

Access to student records and documents must be controlled to ensure integrity, security, and confidentiality. As a student at the University of California, Santa Barbara, the confidentiality of your student information is protected in accordance with the federal Family Educational Rights and Privacy Act (FERPA) of 1974 and University of California, Santa Barbara Policy and Procedure “Student Education Records – Disclosure of Information” issued March 2004 (available from the UCSB Registrar).

Unauthorized use, removal, defacement, or alteration of any physical record or computerized data is prohibited. Providing access to student records or information contained in this application to unauthorized persons is also prohibited.

     
I have read and understand the information above, and by clicking “I AGREE” below give consent for the UCSB Office of Financial Aid and Scholarships SMERF Committee to consult with Student Health Services if relevant to the review of this application. I understand that this release is only in effect for the academic year in which it is enacted.

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.