National Council COVID-19 Relief Fund Member Application

Please note that resources are being collected on an ongoing basis and, as such, donations will be disseminated as they are secured. In an attempt to support as many of our members as possible, we may restrict the amount of financial or in-kind donation that can be requested. If we are unable to provide your organization with the full extent of your request, we will make every attempt to circle back to you if/when further resources are secured. We will disburse all funds on a rolling basis until funds are no longer available. Together, we are America’s behavioral health network.

Please note that organizations can request general support funds AND MHFA Virtual funds. If your organization has already requested general support funds, please complete an additional application to request MHFA Virtual funds (and select “Yes” to question #10)

If you have any questions about the application, please reach out to Jeremy Attermann (JeremyA@thenationalcouncil.org).

*Please note that the National Council is serving as a connecting mechanism for all in-kind donations. While we will do everything we can to ensure that in-kind donations or services are offered as seamlessly as possible, we cannot ultimately claim responsibility for the quality of in-kind donations or services.

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* 1. Address of organization (please list address at which deliveries are received)

Name *

Company *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

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* 2. Is your organization a member of the National Council for Behavioral Health? For a full list of our members, please check our website.

Yes

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* 3. 501c3 Tax Identification Number/EIN #

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* 4. Please confirm the resource you would like to receive:

Unrestricted Funds

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* 5. If unrestricted funds are requested, please identify the specific items/purposes for which funds will be used. You may choose more than one option.

Hand sanitizer

Cleaning supplies

Personal protective equipment (PPE)

Food/meals for clients

Other

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* 6. If unrestricted funds are requested, please indicate your funding request amount. Note that while the National Council will make every attempt to provide funding and support, we cannot guarantee the full amount requested. At this time, please keep your requests up to $1,000

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* 7. Has your organization already applied for general unrestricted funds?

Yes

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* 8. We will be issuing payments via check to expedite the large numbers of funding requests we have received. If the address listed above is different than the address to which this check should be sent, please list that address below. Otherwise, please list "N/A"

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* 9. To expedite payment process, please upload your organization's W-9

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