Volunteer Plus Application

All fields required.

The Nexion Health Foundation (“Foundation”) provides financial assistance to eligible charitable organizations for which Nexion Associates volunteer their time and talent serving their community and supporting the health, well-being, and futures of the elderly and disabled, their families and caregivers. Associates are eligible to apply upon the first of the month following ninety (90) days of consecutive full-time employment. A Volunteer Plus 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. Annual contributions to any one organization shall not exceed $250 and will be limited annually to two (2) organizations per eligible Associate. 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 along with a copy of the organization’s 501(c)(3) letter and W9 form (signed on the most recently available Form W-9), and proof of at least 25 hours of unpaid service to a qualified organization. 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

Date of Hire(Required)

MM slash DD slash YYYY

Legal Name of Eligible Organization(Required)

Community Projects Supported by This Organization(Required)

Volunteer Work Provided to This Organization(Required)

Amount Requested(Required)

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 completed and signed copy of the organizations Form W9 (most recently available Form W-9).
A signed and dated letter on the organization’s letterhead (if available) that verifies your number of hours and description of volunteer work

Federal Tax Exemption Determination(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.

Form W9(Required)

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

A completed and signed copy of the organizations Form W9 (most recently available Form W-9).

Maximum file size - 5 mega bytes.

Volunteer Contributions Verification(Required)

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

A letter from the organization that verifies your number of hours and description of volunteer work

Maximum file size - 5 mega bytes.

Only completed applications with 501(c)(3) letter, W9 form, and proof of volunteer service 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.