Emergency Relief Application

Who is submitting this application?(Required)

This application is being submitted on behalf of a co-worker.

I am submitting this for myself.

Contact Information

In the event this application is being submitted on behalf of a co-worker, please provide the following:

Your Name(Required)

First Last

Your Relationship to Applicant(Required)

Your Daytime Phone(Required)

Your Evening Phone(Required)

Your Email(Required)

Emergency Relief Application

Nexion Health Foundation provides financial assistance to Nexion Associates and their dependents who suffer loss due to widespread natural disasters or other major, unforeseeable, life circumstances. The Emergency Relief Program provides funds for shelter, medical attention, clothing, food, and other basic needs. Nexion Associates are eligible upon their first day of full-time employment.

Date(Required)

MM slash DD slash YYYY

Daytime Phone(Required)

Applicant Name(Required)

First Last

Applicant Title(Required)

Facility Name(Required)

Applicant Email(Required)

Applicant Full Time(Required)

Yes

Date of Hire(Required)

MM slash DD slash YYYY

DATE you talked to your ADMIN prior to submitting this Application?(Required)

MM slash DD slash YYYY

Date/Reason/Outcome of all Applications in Preceding 12 Months:

Applicant Home Address(Required)

Street Address City State ZIP Code

Amount Requested(Required)

Reason for Check(Required)

Describe the Nature of the Emergency in the Space Provided Below(Required)

Documentation

**PLEASE INCLUDE SUPPORTING DOCUMENTATION (INVOICES, RECEIPTS, ETC.) TO FACILITATE REVIEW AND PROCESSING OF APPLICATION**

Supporting Documentation 1

Max. file size: 15 MB.

Supporting Documentation 2

Max. file size: 15 MB.

Supporting Documentation 3

Max. file size: 15 MB.

Apply online by submitting completed application and supporting documentation or submit to:
Nexion Health Foundation, 6937 Warfield Avenue, Sykesville, MD 21784

The Nexion Health Foundation seeks to improve the lives of those who live and work in the communities served by Nexion Health facilities through a variety of financial assistance and gift-giving programs. The Foundation is dedicated to addressing the needs of non-profit organizations and charities that serve the elderly and disabled. The Foundation also funds a variety of programs designed to enrich the lives of Nexion Associates who demonstrate a commitment to long term care. All funding will be determined on a case by case basis and approved by the Foundation Board.

CAPTCHA