HEET Grant Funds Request Form

Welcome to the SEIU Healthcare 1199NW Multi-Employer Training and Education Fund!

This form is for eligible HEET grant participants to request funds which directly support needs related to HEET grant efforts.

Hospital Employee Education and Training (HEET) Grants are partnerships between labor, management, and academia which enhance access to college pathways for healthcare employees. HEET grants seek to strengthen partnerships and increase diversity in the healthcare workforce. Your Training Fund is proud to offer support for your academic journey!

Complete this form to request reimbursement for HEET childcare, technology, and/or transportation costs. Contact your Training Fund education navigator if you have any questions (https://healthcareerfund.org/about-us/staff-directory/).

First Name

Middle Initial

Last Name

Mailing Street (including Apt./Unit)

Mailing City

Mailing State

Mailing Zip Code

Preferred Phone Number

Mobile Phone

Work Phone

Home Phone

Primary Email

Email

Employer

Department

Job Title

Bargaining Unit

Current FTE

Date of Hire

Lead Source

Record Type

Opportunity Name

Opportunity Stage

Please confirm you are enrolled in one of these terms:

What HEET Project are you part of?

What types of costs do you have related to your education program?

Childcare - paying family, friends, or others for childcare so you can study, go to class, and/or receive tutoring.Transportation - gas, car insurance/maintenance, or public transit costs to go to classes and labs.Technology - computers, printers, internet, webcams, headsets, etc. so you can participate in online classes and/or complete homework assignments. Other education related costs not mentioned above

Childcare Costs

How much do expect to spend this HEET project cycle on childcare costs? (cycle is from July 1st - through June 30th the next year - Summer term through Spring term next year)

$

Transportation Costs

How much do expect to spend this HEET project cycle on transportation costs? (cycle is from July 1st - through June 30th the next year - Summer term through Spring term next year)

$

Technology Costs

How much do expect to spend this HEET project cycle on technology costs? (cycle is from July 1st - through June 30th the next year - Summer term through Spring term next year)

$

Other Education Related Costs

How much do expect to spend this HEET project cycle on other education related costs? (cycle is from July 1st - through June 30th the next year - Summer term through Spring term next year)

$

Can you tell us a little bit about these other education related costs that are tied to the childcare, transportation, or technology categories?

Total amount of grant funds requested (each student is limited to $500.00 total reimbursement per HEET grant project):

$

Please provide an example of how you will utilize these funds and how this benefit supports your ability to engage in education successfully (please share your story):

I certify that the amount requested was for eligible expenses incurred while in a HEET education program (during class, study, and/or tutor time, and not while working). I can access documentation to prove these expenses if requested.

I understand the use of these services may be audited. If I can't show documentation matching the amounts claimed, I commit to repaying the Training Fund for any improper funds received. Delays in repayment may affect future Training Fund funding.

I understand that HEET funds are considered taxable income. I am required to submit a W-9 form to the Training Fund, and if I receive $600 or more from the Training Fund within in a given year, I will receive a tax form to use when submitting my annual taxes. Please note: Training Fund staff are not tax professionals; please consult a tax professional for tax assistance.

I understand the amount I will receive will vary depending on funds available, total amount of requests submitted, and my participation in a HEET Grant related education program.

Under penalty of perjury, I state the information provided herein is correct.

True

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