UC San Diego Students with Dependents Assistance Form

If you are a UC  San Diego student with dependent(s) experiencing financial hardship or needing pregnancy, academic, mental health, disability or other resources, please complete this form. Student Affairs Case Management will review your form and provide a scheduling link to meet with a Case Manager to discuss your needs and provide individualized resources and support.

Name Name First Last
Gender Pronouns

Gender Pronouns She/Her/Hers He/Him/His They/Them/Theirs Other Other
PID
UCSD Email
Are you an undergraduate or a graduate/professional student?

Are you an undergraduate or a graduate/professional student? Undergraduate Graduate/Professional
Are you a transfer student?

Are you a transfer student? Yes No
Which graduate and/or professional program are you in?

Which graduate and/or professional program are you in? Professional School (i.e. GPS, Scripps, Jacobs, Rady) Graduate Education Post-Doctoral Affairs School of Medicine Skaggs School of Pharmacy and Pharmaceutical Sciences Other Other
Are you an International student (non-Dream eligible)?

Are you an International student (non-Dream eligible)? Yes No
Housing/Living Status

Housing/Living Status On campus Off campus, within 10 minute drive Off campus, more than 10 minute drive Not currently in stable housing
Did you complete a FAFSA/Dream application for AY 2025-2026?

Did you complete a FAFSA/Dream application for AY 2025-2026? Yes No
Which of the following funding resources do you receive?

Which of the following funding resources do you receive? Financial Aid CalFresh CalWORKS N/A Other Other
Are you currently employed?

Are you currently employed? Yes No
Do you have a Academic Student Employee (ASE) or Graduate Student Researcher (GSR) appointment?

Do you have a Academic Student Employee (ASE) or Graduate Student Researcher (GSR) appointment? Yes No
How many dependents do you care for?

How many dependents do you care for? 0 pregnant or in adoption process 1 2 3 4 or more
Ages of dependents (choose all that apply)

Ages of dependents (choose all that apply) Less than 1 year old 1-2 years old 3-5 years old 6-10 years old 11-13 years old 13-17 years old 18+ Adult with special needs
Would you like to receive our bi-weekly Students with Dependents newsletter? It provides updates on campus and community events and resources for you and your family.

Would you like to receive our bi-weekly Students with Dependents newsletter? It provides updates on campus and community events and resources for you and your family. Yes No
For which of the following are you seeking support or information? (Check all that apply)

For which of the following are you seeking support or information? (Check all that apply) Child and/or adult dependent care Pregnancy and/or postpartum resources Off-campus connections (e.g., children's schools, Regional Center, CalWORKs) Basic Needs (e.g., housing, rent, food) Financial Aid (e.g., Cost of Attendance Appeal, Students with Dependents Verification) Technology (e.g., Wi-Fi, Laptops, etc.) Medical care costs Mental health resources Other (please specify) Other (please specify)
In a few sentences, please explain the circumstances or needs that you'd like to address.