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Home
Who We Are
Our Team
Our Families
Agency Partners
Community Partners & Sponsors
Media Coverage
Our Programs
Back to School Assistance
Kindness Warrior Program
Holiday Assistance
Stabilize Families
Donation & Empowerment Center
How You Can Help
In-Kind Donations
Volunteer
Donate
Contact us
Donate
Holiday Assistance
Gold & Diamond Source Gives Back
Agency Referral Application
Law Enforcement Pick-Up Request
Back to School Assistance
YMCA Employee Assistance
Please Fill Out The Form Below:
Full Name
*
First Name
Middle Name
Last Name
Suffix
Date of Birth
*
MM
DD
YYYY
Please upload a copy of your Photo ID
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
*
Email Address
*
Preferred Method of Contact
*
Phone
Email
Have you completed a minimum 12 months of consecutive service working an average at least one shift per pay period for the YMCA of the Suncoast?
*
Yes
No
Are you currently in good standing with your employer?
*
Yes
No
Personnel file may be reviewed as part of consideration.
Have all other financial resources been exhausted including unemployment benefits, stimulus dollars and employer loans?
*
Yes
No
Have you been awarded any funds from this program previously?
*
Yes
No
How much have you been previously awarded?
*
Enter USD
Did this qualifying event occur in the last 180 days?
*
Yes
No
What type of assistance are you requesting?
*
Please explain the circumstance surrounding your request for assistance.
What amount of assistance are you requesting?
*
Do you have insurance coverage?
*
Yes
No
What insurance deductible applies?
*
Has your insurance provider been notified?
*
Yes
No
If this is a YMCA medical plan, were you eligible for an HRA?
*
Yes
No
N/A
If assistance is for family care, is this legal custody?
*
Yes
No
N/A
This account is funded by a donor that wants to support YMCA staff. Your answer will not impact your eligibility in any way. Would you be willing to:
*
Select All
Allow us to share your story anonymously with the donor
Write a thank you note/message to the donor
I prefer to keep my story private
Application Statement: I have read and fully understand the questions asked in this application. I certify that all of the answers I have given are true, accurate, and complete. I unerstand that the omission and/or misrepresentation of any fact from or on this questionnaire will result in immediate rejection of my application. Unless I noted otherwise, I authorize Hands Across the Bay to contact all of my personal references and do a criminal background check. If assisted, I agree to abide by all rules and regulations of Hands Across the Bay. I understand and agree that nothing in this application shall constitute an offer, a contract, or a guarantee of assistance. I understand that any decision is contingent upon my successful completion of all of the Company's lawful pre-assistance checks, which may include a background check. I agree to execute any consent forms necessary for the Company to conduct its lawful pre-assistance checks. By signing below, I agree to all of the terms stated here.
Signature
*
Date of Application
*
MM
DD
YYYY
Consent
I agree to the privacy policy.
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