Employee Crisis Fund

The Employee Crisis Fund provides funds to employees of Memorial Hospital facing a sudden and urgent situation. Assistance from the fund results in a significant turning point or resolves the crisis. If you are a Memorial employee and would like to apply, please see below. The fund is supported by Memorial employees who give to the fund through our employee giving program, SHINE. If you would like to give to the fund please click here or call Harrison Kajdan at 865-3048.

Eligibility

In order to apply for assistance, you must meet the criteria:

• Employee must have been employed by Memorial full time or PT +20 for at least 90 days, and
• Employee must have successfully completed probationary period, and have no disciplinary actions within the last 12 months or currently under investigation within any major area of concern, and have not submitted resignation or retirement, and
• Situation must be a naturally occurring emergency or catastrophe (fire, flood, tornado, etc) or unavoidable personal emergency (critical illness, unexpected financial loss such as burglary, etc).

The crisis should NOT be a chronic situation of a long duration or a frequent occurrence.

Assistance will be provided by paying bills directly, providing vouchers, etc. Direct payment to the employee is not allowed. We also cannot pay credit card or medical bills. Employees employed 3-6 months are eligible to receive a maximum award of up to $250. Employees employed for 6+ months are eligible to receive a maximum award of up to $500. Employees who have received assistance in the past will be considered on a case-by-case basis.

You will be required to upload your most recent pay stub and copy of bill needing assistance as well as review your application with your supervisor. If you have any questions, please contact Harrison Kajdan at 865-3048 or hkajdan@mhg.com.

Do you understand the eligibility requirements listed above? *

Yes, I understand and meet the eligibility requirements to apply for assistance.

Applicant Information

Name *

First

Last

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Department/Position *

Start Date *

Please check one: *

Full-time
Part-time +20

Supervisor Name *

First

Last

Supervisor Phone *

Crisis Situation Information

Describe your situation below, giving as much detail as possible.

What is the emergency situation and what caused this situation? (Please be as detailed as possible.) *

What have you done to help manage the situation? (Asked for overtime, used savings, received assistance from other organizations or family, etc.) *

What specifically are you asking the Employee Crisis Fund to assist you with and what amount? *

You will be required to upload a copy of the bill further down the application.

Have you applied for assistance from the fund before? If "yes", when and how much did you receive? *

Any other information you would like for the committee to know about this situation?

Financial Information

If it does not apply to you please put "N/A".

Marital Status: *

Single
Married
Divorced
Widowed

Number of dependents: *

Ages of dependents: *

Number of people in the household: *

Monthly Income

If it does not apply to you please put "N/A". You will be required to upload a copy of your most recent pay stub further down the application.

Salary: (gross) *

Spouse's salary or unemployment: (gross) *

Social Security Income: *

Disability: *

Food Stamps: *

Child Support: *

TANF: *

$ from other occupants in the home: *

Retirement: *

Savings: *

Other (please explain): *

TOTAL INCOME: *

Monthly Expenses

If it does not apply to you please put "N/A".

Rent/Mortgage: *

Phone: *

Electricity: *

Water: *

Gas: *

Auto payment: *

Auto insurance: *

Food: *

Medical Insurance: *

Prescriptions: *

Child Care: *

Cable/Internet: *

Credit Cards: *

Other Loans (please explain): *

TOTAL EXPENSES: *

Required Attachments

Please upload a copy of the bill needing assistance. *

Click or drag a file to this area to upload.

(Files must be one of the following: .png, .jpg, .doc, .xls, .pdf and no larger than 32MB)

Please upload a copy of your most recent pay stub. *

Click or drag a file to this area to upload.

(Files must be one of the following: .png, .jpg, .doc, .xls, .pdf and no larger than 32MB)

Agreement

I certify that the information contained in this application is correct to the best of my knowledge and I have reviewed my application with my supervisor.

Signature of Applicant *

Clear Signature

Use your cursor to sign electronically.