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Michael R. Walker Foundation
Home
Who We Are
Make a Donation
Request a Grant
Grant Recipients
Contact
Giving, Helping, Caring
MRWF - Medical Grant Application
Step
1
of
2
50%
Name
This field is for validation purposes and should be left unchanged.
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)
PA
NH
NM
Powerback
WV South
WV North
MA/CT/RI
ME/VT
DE/VA/MD
Mid-Atlantic
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)
Date(s) of Hardship
(Required)
Please describe what the medical condition is and the hardship/situation details
(Required)
Family/Household Demographics
Number of Adults
(Required)
Number of Children
(Required)
Relation to Employee
(Required)
Do you have related medical bills?
(Required)
Please select
Yes
No
If Yes, please upload related medical bills.
Max. file size: 2 GB.
If you are unable to upload, please fax to 610-347-6217 or email to mrwfoundation@genesishcc.com
Total of all medical bills related to this hardship
(Required)
Have you applied for charity care or other financial assistance with the provider(s)?
(Required)
Please select
Yes
No
Have you tried to set payment arrangements/plans with the provider(s)?
(Required)
Please select
Yes
No
Is the person by medical insurance?
(Required)
Please select
Yes
No
Does the person have access to other medical coverage?
(Required)
Please select
Yes
No
If Yes, indicate type of coverage (Company, Spouse, CHIP, Medicaid, Medicare, Other)
Are you on an approved FMLA/Leave of Absence?
(Required)
Please select
Yes
No
If Yes, please upload approved FMLA/Leave paperwork.
Max. file size: 2 GB.
If you are unable to upload, please fax to 610-347-6217 or email to mrwfoundation@genesishcc.com
Have you exhausted your Paid Time Off (PTO)?
(Required)
Please select
Yes
No
Did you lose wages that we can document via payroll?
(Required)
Please select
Yes
No
Do you have disability benefits - please let us know what you have
(Required)
Was your hardship related to an injury at work?
(Required)
Please select
Yes
No
If yes, have you filed for Worker’s Compensation?
(Required)
Please select
Yes
No
Was your hardship due to an auto accident?
(Required)
Please select
Yes
No
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)
Acknowledgment
(Required)
I certify that the information I have provided in this application is true, accurate, and complete, to the best of my knowledge. I understand that submitting false information will result in the rejection of my application.
Please just check the box, no electronic signature is required.
This field is hidden when viewing the form
Grant Coordinator
Grant Amount Awarded
This field is hidden when viewing the form
Grant Notes:
Untitled
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