Blue Cross Blue Shield Student Assistance Application

Student Assistance Application Form

Please fill out the following form completely. All fields are required unless otherwise indicated.

Full Name

Student ID Number

Program of Study

Do you have a GPA of 2.0 or higher?

YesNo

Type of Assistance Requested

Please select one of the following types of assistance you are requesting:

Food assistanceAuto repairs and housing needsTransportation assistance

Explanation of Need