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Who We Are
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How You Can Help
Contact us

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 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
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
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