Employee Emergency Fund

Application Form

 

The purpose of the Employee Emergency Fund (EEF) is to provide limited financial assistance for employees of Rowan Regional Medical Center. The funds are to be used as a last resort for basic needs (i.e. food, clothing and shelter) when all other resources fail. It is short-term help for emergencies. Requests up to $300 will be considered.

To be eligible, one must:

  • Be a Rowan Regional Medical Center/Novant Health employee, including full-time, part-time, PRN employees and Novant corporate employees based at Rowan Regional Medical Center
  • Have completed their introductory period of 90 days
  • Have not received money from the fund in the last 12 months
  • Have no one else in the immediate family who has received money from the fund in the last 12 months

 

To apply:

Please contact the Employee Emergency Fund Representative at 704-210-5999 to set up an appointment to complete the application.

  • Complete the application
  • Bring a recent pay stub with you
  • Bring bill or letter stating how much you owe and to whom
  • Submit a letter, providing a clear description of the need, how this money will benefit you and how you plan to address long-term solutions to your problem

 

All information about anyone requesting funds is confidential, and no repayment of funds is required. All decisions of the EEF Review Committee are final.

 

The EEF Review Committee will not be aware of the identity of the employee making the request.

 

Checks will be made payable to a community organization, agency or third party (i.e. electric, gas and water company).

 

The Employee Emergency Fund is made possible through gifts from your fellow employees. Only a limited amount of money is available. Upon depletion of funds, requests will not be reviewed until fundraising activity restores the Fund.

 

INVITATION TO SUBMIT AN APPLICATION DOES NOT GUARANTEE SELECTION TO RECEIVE FUNDING.

 

 

Employee Emergency Fund Application Form

Please print the following information:

 

Date: ____________________ Date of Employment: _________________

 

Name: _______________________________________________________

Last

 

Home Address: ________________________________________________

City State Zip

 

Home Phone: ____________________  Work Phone: __________________

 

Employee ID #: __________________    Social Security #: ______-___-____

 

Novant Health Department: ______________________ Shift:____________

 

Have you or anyone in your immediate family received EEF funds in the past year?____ Yes __ No

If yes, who and on what date? ______________________________________

Number of people in household: ______________________

 

 Names of those in household  Age  Occupation or Student
     
     
     
     
     
     

 

 

 

 

 

 

 

 

 

 

 

FOR OFFICE USE ONLY Application # ___________________

Review Committee Action:

Specific reason for requesting assistance:

 

 

 

 

What help have you tried to get for this problem? Check all that apply.

 ___Family   ___Crisis Assistance Ministry___ Consumer Credit Counseling

 ___Rowan Helping Ministries Others _______________________


List any other support already received and/or pledged. Include sources and contact information and amounts. _________________________________

____________________________________________________________

How many hours of PTO do you have?____

Have you sold any PTO this year? ___Yes ___No

If YES, how many hours?_________

Hourly Wage: ____________________________

Net Monthly Income: __________________________

Spouse/significant other income: ______________

Total net monthly household income: _____________ (from all sources)

Savings: ____________________________

 

Monthly Bills:

        Rent/Mortgage: _________________     Other: ________________________

        Utilities: ______________________                  ________________________

        Car/Car Ins.:___________________                 ________________________

        Phone: _______________________                 ________________________

        Other: ________________________      

 

How much financial assistance would you like to receive? $___________

NOTE: Checks will be made only to a community organization, agency or third party.

 

May we contact your supervisor if needed?  ___Yes   ___No

If yes:  Name ________________________ Extension: __________________

 

Human Resources will be contacted to verify employment date and status.

 

Applicant Signature: _____________________________  Date: ____________

 

FOR OFFICE USE ONLY                       

Employee Emergency Fund Representative Comments:

 

 
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