Domestic Abuse Grant Application – Michael R. Walker Foundation

MRWF - Domestic Abuse Grant Application

Please Note: To be considered for relocation of safe affordable housing, the employee must have an active Protection from Abuse Order. If you feel like you are in immediate danger or a life-threatening situation, please contact 911 immediately.

Step 1 of 2

Employee Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Employee ID(Required)

Home Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

County of Residence(Required)

Center/Site Location(Required)

Please select Division/Market that applies to you(Required)

Job Title(Required)

Hire Date(Required)

Shift/Time usually at work(Required)

Employment Status(Required)

Hours Per Week(Required)

Who is filing out the form?(Required)

If not applicant, please supply name, title and relationship to employee(Required)

Additional Details

Please note, if the employee is still residing with the abuser, they must contact the National Domestic Violence Hotline at 800-799-SAFE (7233) or other Domestic Violence agency. The Foundation cannot consider employee applications until you/they are working closely with a professional domestic abuse resource. You can also get started at EAP/Health Advocate at 877-240-6863 for support services.

An Active Protection from Abuse Order is Required. Does the employee have one?(Required)

If Yes, please upload the Protection from Abuse Order

Max. file size: 768 MB.

If you are unable to upload, please fax to 610-347-6217 or email to mrwfoundation@genesishcc.com

Date(s) of Hardship(Required)

Please describe hardship/situation details(Required)

Describe where the employee is currently living.(Required)

Please describe if/how any children or dependents are currently affected by the situation.(Required)

Have you been able to contact the National Domestic Violence Hotline at 800-799-SAFE (7233) or (TTY) 800-787-3224, or other domestic abuse agency or resource center?(Required)

What specific help is needed from the Foundation?(Required)

Describe where the employee is currently living.(Required)

Funds

Requested Amount(Required)

How will grant funds be used?(Required)

If a grant is approved, will you allow MRWF to share your story?(Required)

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Grant Coordinator

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Grant Notes:

This field is for validation purposes and should be left unchanged.

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MRWF - Domestic Abuse Grant Application

Employee Information

Additional Details

Funds