Mental Health Emergency Fund Application 2026-27

This form is monitored by the Student Mental Health Emergency Fund committee, please contact Darlene Schmitt, Counseling Center Director with questions at dschmitt@brockport.edu

BACKGROUND INFORMATION
Name Name First Last
Banner ID
Must be 9 digits. Currently Entered: 3 digits.
Brockport Email
Select the "Continue" button below to begin this application.

Be aware that your work is not automatically saved! To do so, go to the bottom of any page and check the box next to "Save my progress and resume later".
Preferred Mailing Address Preferred Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Campus Mailing Address
Phone Phone - ### - ### ####
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

Mental Health Emergency Fund Application 2026-27

BACKGROUND INFORMATION

Select the "Continue" button below to begin this application.