Application for Emergency Assistance

Applicant Information

Employee Name

Email Address

Cell Phone

Employee SSN

For Employee SSN: The - symbol must be used between the groups of numbers. E.g. 111-11-1111. Error 1.1 would signify an invalid SSN or invalid formatting.

You will be notified of your Emergency Assistance application status by email. Please verify that you have provided valid contact information. You will only receive communication concerning your application.

Emergency Information

Reason for Support

Amount Requested

$200 is the max for Campus Funds

Amount Requested

$1000 is the max for Foundation Funds

Have you received an emergency assistance award within the last 12 months?

YesNo

Please provide a detailed explanation for your request including details of both the cause(s) and effect(s) of your emergency. Lack of detail, and documentation if requested by your Executive Director, will result in a decreased chance of your request being funded.

Documentation

In order to be good stewards of the donations that are provided to us we require verification of an emergency in most situations. This verification is generally in the form of a payment receipt, an estimate from a company, or something else of this nature.

If you are able to upload this documentation here it may be able to greatly increase the speed in which the Foundation can make a final decision on the request.

Documentation Upload 1

Documentation Upload 2

Documentation

Documentation Upload 1

Documentation Upload 2

PTO Needed due to Coronavirus

I am out of PTO hours due to Coronavirus, and I would like to request additional hours be donated to me.

How many hours are you requesting?

Coronavirus Impact Assistance

Schools nationwide are closing until further notice to prevent the spread of Coronavirus amongst vulnerable populations. Unforeseen costs such as childcare and meals have the potential to hit Trilogy family members throughout the company. To help, the Trilogy Foundation is prepared to offer meal assistance for children enrolled in programs at school when the school is closed because of Coronavirus free/discounted meals.

Please answer the following question(s) to see if you are eligible for this assistance:

Are you Full or Part Time (Not PRN)?

Is your local school system currently closed?

Do you have children that are 17 years old or younger?

Do you have children in Elementary or Middle School?

Do you work first shift this week?

Not Currently Eligible

It does not appear that you are currently eligible for this assistance. Please return to this form if you become eligible in the future.

Emergency Food Assistance

Emergency Food Assistance:

Eligibility:
1. Must be a full or part time employee of Trilogy Health Services, Paragon Rehabilitation, or PCA Pharmacy.
2. Children must be 17 years old or younger and a financial dependent of the employee.
3. Children must be enrolled at a school that has closed as a result of Coronavirus (COVID-19). Employees with children who are still in school with no closures are not eligible for food packages at this time.
4. Families that are currently participating in a free and discounted meal program.

Click here to view the full Emergency Food Assistance Policy

Number Dependents (17 or Younger that Live with You)

I would like to be considered for Food Assistance.

Your Shipping Address

Your Shipping City

Your Shipping State

Your Shipping Zip Code

Childcare Assistance

How many children in Elementary or Middle School do you have?

I would like to be considered for Childcare Assistance for this week.

The Trilogy Foundation seeks to provide support to employees in times of catastrophic events. A committee will review all requests for assistance. Awards are determined on a case-by-case basis and the amount of your assistance may not equal the amount you have requested. Depending on the situation, you may be asked to provide documentation that supports the details of your emergency.

Contact Information