Helping Hands Application

Helping Hand Gift Request Application
Team member Name*

First NameLast Name
Team member number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please use an email address that you can easily access to ensure effective communication.
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of hire*

MonthDayYear
Date
Gift Request Date*

MonthDayYear
Date
Employment Status*
Shift Status*
Are you supplementing your loss with time-off bank?*
Reason for Request*
Team Member Area of Greatest Need*

MortgageRentAuto LoanOther LoanAuto InsuranceCOBRAOther

Additional Comments
There are resources available through our relationship with Capital Area Michigan Works (CAMW). Do we have your authorization to submit a referral to CAMW, on your behalf?*

YesNo
I confirm that the above information is accurate and authorize Helping Hand's representatives to verify it through Human Resources. If approved, I understand that payment will be processed through U of M Health-Sparrow’s payroll cycles and will be subject to taxes.

I acknowledge that this information will be kept confidential and shared solely with the Helping Hand's Committee.
Signature*
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Helping Hand Gift Request Application