Application for Emergency Assistance
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Argentum?
Please select...
1
2
3
Removed from 1
Completed Heroes Survey?
Please select...
Yes
No
Happy Feet?
Please select...
Yes
No
No
Applicant Information
Employee Name
Email Address
Cell Phone
Employee ID
What is your total household income?
Please select...
less than $25,000
$25,000 to $50,000
$50,000 to $75,000
$75,000 to $100,000
$100,000 or more
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.
Are you applying for Emergency Assistance or free shoes through Happy Feet?
Please select...
I am applying for Emergency Assistance
I am applying for Happy Feet
Emergency Information
Please DO NOT fill out this Emergency Assistance request for the Happy Feet shoe program. The Happy Feet program is closed for now.
Reason for Support
Please select...
Life Threatening Medical Crisis-Foundation Funds
Death of Immediate Family Member-Foundation Funds
Catastrophic Loss of Property-Foundation Funds
Domestic Violence Situation-Foundation Funds
Non Life Threatening Medical Crisis-Campus Funds
Home Eviction-Campus Funds
Utilities Shut Off-Campus Funds
Car Payment or Repairs-Campus Funds
Food Assistance - Campus Funds
Other Circumstances-Campus Funds
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?
Yes
No
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
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
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.
Please select...
Yes
No
How many hours are you requesting?
Which Emergency Assistance are you applying for? (Check All That Apply)
Childcare (Up to $200 award)
Food/Housing (Up to $200 award)
Community Needs Survey - Earn a $100 Wal-Mart Gift Card
Would you like to earn a $100 Wal-Mart Gift Card? Our non-profit partner, Family Scholar House, is offering a $100 gift card to employees to complete the Community Needs questionnaire? This questionnaire will take 5-10 minutes to complete. You will be redirected to the questionnaire when you submit this form. You must complete the entire survey to receive payment and there is a limit of one gift card per employee. Please do not share this survey link, it is unique to you.
Please select...
Yes
No
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.
Happy Feet Show Information
Video Information
Did you watch the video?
Yes
No
Shoe Information
Mens/Womens Shoe
Please select...
Mens
Womens
Shoe Style
Please select...
Brooks Ghost 14
Brooks Adrenaline 21
Show Size
Please select...
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
12.5
13
13.5
14
Shoe Width
Please select...
Medium
Wide
Extra Wide
Ghost 14 Men's Color Choices
Color Choice First Choice
Please select...
Black/Black
Grey/Blue
Color Choice Second Choice
Please select...
Black/Black
Grey/Blue
Black/Black
Grey/Blue
Ghost 14 Women's Color Choices
Color Choice First Choice
Please select...
Black/Pink
Peacoat/Navy
Color Choice Second Choice
Please select...
Black/Pink
Peacoat/Navy
Black/Pink
Peacoat/Navy
Adrenaline 21 Men's Color Choices
Color Choice First Choice
Please select...
Grey/Blue
Black/Nightlife
Color Choice Second Choice
Please select...
Grey/Blue
Black/Nightlife
Grey/Blue
Black/Nightlife
Adrenaline 21 Women's Color Choices
Color Choice First Choice
Please select...
Grey/Atlantis
Iris/Lilac
Color Choice Second Choice
Please select...
Grey/Atlantis
Iris/Lilac
Grey/Atlantis
Iris/Lilac
May we contact you about the Happy Feet Program?
Yes
No
Community Needs Survey
Once you submit this form you will be redirected to a survey. YOU
must complete the survey to receive your shoes.
This survey is being conducted by our partner, Family Scholar House, to craft their program to better suit the needs of our communities. The survey takes 5-10 minutes to complete.
The 200 pairs of shoes for Kentucky have all been claimed. You may submit this form and complete the following survey to be put on an alternate list to receive a pair of shoes should more shoes become available. Thank you for your interest in the Happy Feet program.
Contact Information