Graduate Student Government Family Assistance Grant
The Family Assistance Grant is intended to help defray the costs of child care services and health insurance for graduate
students with children while attending the Colorado School of Mines. This scholarship is funded by the Graduate Student
Government (GSG) and the Colorado School of Mines.
To be eligible for this scholarship, you must:
1) be a full or part time graduate student at the Colorado School of Mines,
2) be in good academic standing as defined in the Graduate Bulletin,
3) have at least one child of preschool age (under 6 years of age) attending a licensed daycare service
4) have a child or children and a spouse without medical insurance coverage available outside of the Student Health
Insurance Plan (SHIP), and
5) have documented financial need.
In determining financial need several factors are considered. Among these are household income, educational expenses,
other non-documented sources of income and whether or not subsidized access to daycare services or health insurance
through another program are available. Awards through this program aare made semi-annually (beginning of Fall and
Spring semesters) on a competitive basis. Currently, the amount of the awards are for $125 per month for a 10 month
duration spanning the school year (August through May), for a total off $1250, payable in two installments, one each
semester. As awards are given in the form of a grant based on financial need, thesee may, depending on the awardee's
individual circumstances, be tax exempt.
The applications are evaluated by the GSG Family Assistance Grant Advisory Committee. This committee is comprised
of 5 members and is charged with evaluating and ranking applications based on the criteria defined above. The Advisory
Committee makes its award recommendations to the GSG Executive Committee. The Executive Committee then makes
the final decision regarding the awards. For the purposes of evaluating applications to the Family Assistance Grant
program, the Dean of Graduate Studies is a voting ex officio member of both the Advisory and Executive Committees.
If you are denied an award and extenuating or other mitigating circumstances exist, you may appeal the award decision.
Appeals are considered by the Executive Committee, they must be made in writing and they must be received by the
Executive Committee no later than 5 business days after initial notificcation of the award. Examples of extenuating
circumstances that would be considered include, but are not limited to: a sudden illness in the immediate family, large
medical bills, or recent loss of a job.

GSG Family Assistance Grant Application
Fill out this form and return it and all necessary documentation as noted below to the Office of Graduate Studies by the
application deadline.
Full Name ____________________________________________________________________
Street Address ___
City ______________________________ State _______________ Zip ___________________
Phone _____________________________ Student ID # ______________________________
Gross Adjusted Income (entire household, last year) ________________________
Do you (or does your spouse) pay your CSM tuition? Y N
If yes, please indicate the cost of your tuition last year _____________________
Total number of children _______________
Ages of children (e.g.: 9 mo, 2 1/2 yrs) _______________________________________
Is at least one of your children currently enrolled in a licensed day care? Y N
If yes, is s/he enrolled Fulltime or Part-time (please circle one)?
Do you/does your spouse have another employer who also provides a child care subsidy? Y N
If yes, amount of that subsidy (annually) __________________________________
Does any member of your immediate family (spouse and/or children) have access, through an employer or
otherwise, to health insurance with a similar cost and similar coverage/benefits to the SHBP, except
through you? Y N
Do you currently pay for the SHBP for your immediate family? Y N
If yes, amount you pay (annually) ______________________________________
Please attach to this application form:
1) a copy of last year's tax return, indicating income
2) a copy of the child care contract, if your child is currently enrolled iin day care
3) a copy of your student account indicating payment for the cost of the SHBP for your immediate family
4) a list of loans you are currently receiving
5) a brief statement indicating how you currently are meeting your tuittion and living expenses
I assert that, to the best of my knowledge, this form has been completed truthfully:
Applicant Signature ______________________________________________ Date __________