Employee Assistance Request Form

Power Outage Crisis | East Region

Munson Healthcare Foundations has set up an interim program to assist employees suffering hardship.

Please read the entirety of this application including all eligibility requirements.
Application must be completed (fully).
Please submit your request by 5 pm on April 21, 2025.
Requests after this date will not be considered. A designated external committee has been assembled to review all requests. Munson will consider decisions final, based on the committee’s recommendations.
Maximum request for financial assistance is $500.00 per employee or household (if more than two employees work for MHC and request).
Vendor must accept credit card payment; no other method of payment can be made.
Payment is not made directly to employee. It’s paid to the vendor.
Insurance-related costs are not eligible (e.g., deductibles, etc.)
As we are using philanthropy dollars, there are limited funds available, and we will not be able to support every request.