Student Wellness Center

Sexual Violence Assistance Fund Application

In order to begin the application process, students may complete the form below.

Currently enrolled OSU students are eligible to apply for funding if they allege to a university official that they have experienced sexual violence.

Eligibility for funds will be determined on a case-by-case. Each request will be evaluated based on all relevant considerations, including but not limited to: the nature and extent of the support requested, accompanying documentation, and the availability of alternative university or community resources or sources of funding. First priority will be given to requests for funding relating to medical care or treatment. Whenever feasible, payment will be made directly to the entity providing the service or items.

Please note that there is a $500 maximum cap per case.

Student Information

*Name:

Phone Number:

Format: 614-123-4567

*Email Address:

*Address:

*City:

*State:

*Zip Code:

*Amount Requested:

*Please describe the basis of your request for assistance:

I was made aware of this fund by (please check all that apply):

Wilce Student Health Center
OSU Medical Center
Counseling and Consultation Service
Student Wellness Center
Student Advocacy
Other

If Other, please list:

*Terms:

I acknowledge that the information provided on this application and any supporting documents, materials or representations is true and accurate to the best of my knowledge.

I understand that neither the submission of this application nor the receipt of assistance funds implies or establishes that a crime or violation of the Code of Student Conduct or other university policies has occurred.

Information pertaining to a request for funding will be kept confidential to the extent feasible. I understand that this application does not constitute a report of sexual violence. If I choose to initiate a report, I will follow all applicable procedures, including the filing of a police report and/or a complaint with the Office of Student Judicial Affairs and other university offices as appropriate.

I hereby grant permission for the Student Wellness Center to contact other university and community resources (e.g. Victims of Crime Compensation) to verify the status of other requests for financial assistance as applicable. I agree to sign any additional paperwork that such other resources may require in order to grant the Student Wellness Center access to this information. I understand that I will be contacted by the Student Wellness Center to schedule an appointment to aid in the review of my application. As part of this meeting, I may provide supporting documentation of my claim/need.

I agree that any funds received will be used only for the purpose(s) for which they were allocated. I understand that I may be required to return any assistance funds that are received improperly or that are used for any unauthorized purpose.

I agree to these terms.

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