One 4 One Giving Application

All fields required.

The Nexion Health Foundation (“Foundation”) matches donations made by eligible Nexion Associates to one qualified local, regional, or national charitable organization per year through the One 4 One Giving Program. Associates are eligible to apply upon the first of the month following ninety (90) days of consecutive full-time employment. A One 4 One Giving contribution check will not be made payable to an individual. Annual contributions are at the discretion of the Foundation Board of Directors and based on a review of the available information. The Foundation reserves the right to limit financial assistance and to limit annual contributions made to any one charitable organization as the Foundation does not have the financial resources to approve all the requests submitted.

To apply, complete and submit this Application form online, along with a copy of the organization’s 501(c)(3) and proof of your contribution(s). Please see below for further requirements.

Date(Required)

MM slash DD slash YYYY

Daytime Phone(Required)

Applicant Name(Required)

First Last

Applicant Title(Required)

Applicant Email(Required)

Facility Name(Required)

Applicant Full-Time(Required)

Yes

Legal Name of Charitable Organization(Required)

Community projects supported by this organization(Required)

Amount Requested(Required)

Date of Hire(Required)

MM slash DD slash YYYY

Organization Contact Information

Contact Person(Required)

First Last

Phone(Required)

Fax(Required)

Email Address(Required)

Website(Required)

Address of Organization(Required)

Street Address City State ZIP Code

PLEASE SUBMIT THE FOLLOWING DOCUMENTATION:

A copy of the organization’s IRS Federal Tax Exemption Determination (501(c)(3) Letter)
A dated receipt from the organization which documents your personal contribution(s) during the current calendar year
A copy of your cancelled check or a detailed credit card statement that verifies your personal contribution during the calendar year.

Federal Tax Exemption(Required)

Accepted file types: pdf, doc, docx, Max. file size: 5 MB.

A copy of the organization’s IRS Federal Tax Exemption Determination (501(c)(3) Letter)

Maximum file size - 5 mega bytes.

Personal Contribution: Receipt(Required)

Accepted file types: pdf, doc, docx, Max. file size: 5 MB.

A dated receipt from the organization which documents your personal contribution(s) during the current calendar year

Maximum file size - 5 mega bytes.

Personal Contribution: Statement(Required)

Accepted file types: pdf, doc, docx, Max. file size: 5 MB.

A copy of your cancelled check or a detailed credit card statement that verifies your personal contribution during the calendar year

Maximum file size - 5 mega bytes.

Only completed applications with the 501(c)(3) letter and proof of contribution(s) submitted online will be accepted for review.

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.